Oncology Nurse Advisor January/February 2019

www.OncologyNurseAdvisor.com

January/February 2019

A F O R U M F O R P H YS I C I A N A S S I S TA N T S

irAE MANAGEMENT

FEATURE

How Much Faith Do Patients Put in Alternative Medicine?

NAVIGATOR NOTES

Culturally Competent Care for Jewish Women With Breast Cancer

COMMUNICATION CHALLENGES

A Call to Support Our Young Nurses

ISSUES IN CANCER SURVIVORSHIP

Chemo Brain Gets a Novel Intervention

THE TOTAL PATIENT

Integrative Medicine for Pediatric Oncology Patients

RADIATION & YOUR PATIENT

Fertility Preservation Comes to the Forefront of Radiotherapy

ASK A PHARMACIST

Substitute for Lidocaine

Using Fecal Microbiota Transplantation to Treat ICI-Associated Colitis ICI therapy can eradicate bacteria and microbes (inset) essential to a healthy colon, leading to treatment-related colitis.

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PUBLISHING STAFF

EDITORIAL BOARD

Editor Joyce Pagán editor.ona@haymarketmedia.com

Account manager Henry Amato (646) 638-6096 henry.amato@haymarketmedia.com

Eucharia Borden, MSW, LCSW, OSW-C Lankenau Medical Center Wynnewood, Pennsylvania

Senior digital content editor Rick Maffei

Manager, Multi-channel business development, Haymarket Oncology Marc A. DiBartolomeo (609) 417-0628 marc.dibartolomeo@ haymarketmedia.com

Ann J. Brady, MSN, RN-BC Huntington Cancer Center Pasadena, California

Associate account manager Kate O’Shea (646) 638-6028 kate.oshea@haymarketmedia.com

Jiajoyce R. Conway, DNP, CRNP, AOCNP Cancer Care Associates of York York, Pennsylvania

Oncology writer Susan Moench, PhD, PA-C Contributing writer Bette Weinstein Kaplan Group art director, Haymarket Medical Jennifer Dvoretz Graphic designer Vivian Chang Production editor Kim Daigneau

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

Production director Louise Morrin Boyle

General Manager, Medical Communications Jim Burke, RPh

Production manager Brian Wask brian.wask@haymarketmedia.com

President, Medical Communications Michael Graziani

Circulation manager Paul Silver

CEO, Haymarket Media Inc Lee Maniscalco

Haymarket Media Inc Sales and Editorial offices 275 7th Avenue, 10th Floor, New York, NY 10001; (646) 638-6000 Subscriptions: www.OncologyNurseAdvisor.com/freesub Reprints: Wright’s Reprints (877) 652-5295 Permissions: www.copyright.com Unless otherwise indicated, persons appearing in photographs are not the actual individuals ­mentioned in the articles. They appear for illustrative purposes only.

Oncology Nurse Advisor (ISSN 2154-350X), January/February 2019, Volume 10, Number 1. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved.

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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 Leah A. Scaramuzzo, MSN, RN-BC, AOCN Kalispell Regional Healthcare Kalispell, Montana Lisa A. Thompson, PharmD, BCOP Kaiser Permanente Colorado Rosemarie A. Tucci, RN, MSN, AOCN Lankenau Hospital Wynnewood, Pennsylvania Kara M. L. Yannotti, MMH, BSN, RN, CCRP John Theurer Cancer Center at Hackensack University Medical Center Hackensack, New Jersey

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CONTENTS 4

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January/February 2019

IN THE NEWS • Preferred Attributes of PI Therapy for R/R MM • Acupuncture Eases Some Self-Reported Symptoms of Cancer and Treatments • Common Reasons for Discontinuation of Oral Chemotherapy for Kidney Cancer • Postmastectomy Breast Reconstruction Safe in Older Women • Radical Prostatectomy vs Active Surveillance: Results of Nearly 3 Decades of Follow-up

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• Mini-Pools of IVIG Just as Effective as Standard IVIG in Pediatric ITP • HNC Survivors Continue to Experience CSS at 1 Year or More Posttreatment … and more

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NAVIGATOR NOTES How Culturally Competent Care Differs for Jewish Women With Breast Cancer Megan Garlapow, PhD

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FEATURES FMT Offers Promising Strategy Against ICI-Associated Colitis Bryant Furlow

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FIND US ON

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How Much Faith Do Patients Put in Alternative Medicines?

Bryant Furlow

OncologyNurseAdvisor.com

@ONAcom

linkedin.com/company/oncology-nurse-advisor

facebook.com/OncologyNurseAdvisor plus.google.com/+Oncologynurseadvisor

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www.OncologyNurseAdvisor.com

JOURNAL REVIEW Regular Physical Activity — Even Initiated Postdiagnosis — Improves Survival for Cancer Patients

DBBR data demonstrated that regular recreational physical activity may reduce the risk of all-cause and cancer-specific mortality in both habitually active and newly active lifestyles.

John Schieszer, MA

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JOURNAL REVIEW Safety of B12 Supplement, Pemetrexed Infusions on the Same Day

ISSUES IN CANCER SURVIVORSHIP

John Schieszer, MA

Proscription on Antiperspirant Use During Radiotherapy: Does the Advice Still Apply?

RADIATION & YOUR PATIENT Fertility Preservation Comes to the Forefront of Radiotherapy

Bette Weinstein Kaplan

Researchers determined that antiperspirant/ deodorant use does not increase the risk of skin reactions in the axilla.

Bryant Furlow

FACT SHEETS 20

COMMUNICATION CHALLENGES A Call to Support Our Young Nurses Ann J. Brady, MSN, RN-BC, CHPN

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ISSUES IN CANCER SURVIVORSHIP Cancer-Induced Cognitive Impairment, aka Chemo Brain, Gets a Novel Intervention Bette Weinstein Kaplan

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THE TOTAL PATIENT Integrative Medicine for Children: Practices That Can Help Pediatric Patients Bette Weinstein Kaplan

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FROM CANCERCARE The Role for Wounded Healers in Oncology Nursing

Physical Activity and Cancer

This fact sheet examines the role of physical activity and exercise in cancer prevention and cancer survivorship.

Hormone Therapy for Breast Cancer

This fact sheet reviews the use of hormone therapy in breast cancer therapy and possible side effects of treatment.

PUBLISHERS’ ALLIANCE: DOVE PRESS CART Cell Therapy for Prostate Cancer: Status and Promise

This review summarizes the present use of CAR-T cells in the treatment of prostate cancer and discusses the promise of the application of this technology to prostate cancer therapy.

OncoTargets and Therapy

Richard Dickens, MS, LCSW

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ASK A PHARMACIST Preinfusion Amino Acid Solution; Injection-Site Pain Lisa A. Thompson, PharmD, BCOP

ON THE

WEB

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2019 • ONCOLOGY NURSE ADVISOR 3

IN THE NEWS Preferred Attributes of PI Therapy for R/R MM Combination treatments including novel proteasome inhibitors (PIs) provide more options for patients with relapsed/ refractory multiple myeloma (R/R MM). In this study, preferences among combinations of 4 treatment attributes were assessed in 84 adults with R/R MM. These included treatment regimen, duration of time without disease progression, and possibilities of grade 3 or higher adverse events (AEs) involving either the blood or heart failure.

Therapy application regimens included once-daily oral intake and the following 3 options: additional onceweekly oral intake with 1 monthly physician visit, additional twice-weekly oral intake with 1 monthly physician visit, or additional once-weekly oral intake with twiceweekly physician visits featuring intravenous infusions.

Duration without disease progression included options of 17, 20, or 26 months. Hematologic grade 3 or higher AE probabilities included 12 vs 19 of 100 patients. Grade 3 or higher AE-related heart failure probabilities included 2 vs 4 of 100 patients.

Patients ranked attributes in the following order of importance: treatment application regimen (38.8%), duration without disease progression (38.7%), possibility of heart failure as an AE (13.9%), and possibility of hematologic AE (8.6%).

Once-daily plus once-weekly exclusively oral therapy was the preferred administration, and patients preferred longer times without disease progression as well as lower risks of adverse events. However, many were willing to limit progression-free time for all-oral therapy and lower risk of AEs. Matching these preferences to attributes of existing combination treatments showed lenalidomide with dexamethasone plus ixazomib ranked highest, lenalidomide with dexamethasone without a PI ranked second, and lenalidomide with dexamethasone plus carfilzomib ranked third.

Progression-Free and Overall Survival Improved With Sequential RB/RC in uMCL Standard-of-care therapy for transplant-eligible (TE) patients with untreated mantle cell lymphoma (uMCL) is induction chemotherapy followed by autologous stem cell transplantation (ASCT); however, no consensus is established for an optimal induction regimen. Rituximab plus high-dose cytarabine (RC) added to an RCHOP-like regimen has been shown to be associated with better outcomes; however, rituximab/ bendamustine (RB) was shown to have superior efficacy and tolerability than RCHOP in this patient population.

Therefore, researchers at Dana-Farber Cancer Institute (DFCI) in Boston conducted a phase 2 trial to determine

progression-free survival (PFS) and overall survival (OS) with sequential cycles of RB and RC in patients with uMCL. In a separate trial, occurring simultaneously, researchers at Washington University School of Medicine (WUSTL) in St Louis, Missouri, were investigating rituximab with bendamustine in alternating cycles with rituximab plus high-dose cytarabine in patients with uMCL. In the DFCI trial, 23 TE patients with uMCL received 3 cycles of RB (rituximab 375 mg/m2 on day 1 and bendamustine 90 mg/m2 on days 1 and 2) followed by 3 cycles of RC (rituximab 375 mg/m 2 on day 1 and cytarabine 3 gm/m2 on days 1 and 2 with dose reductions for age, renal dysfunction, or pre-existing neurotoxicity). In addition, 49 patients, retrospectively identified from clinical and pharmacy

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© BIOPHOTO ASSOCIATES / SCIENCE SOURCE

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

databases, were treated off-trial at DFCI or a community practice. Response assessments were made using CT scans in the trial patients and PET/CT in the off-trial patients.

In the WUSTL trial, 14 TE patients received the same doses as in the DFCI trial but in alternating cycles: RB in cycles 1, 3, and 5; and RC in cycles 2, 4, and 6. Patients in this trial were more likely to be male, have a high MIPI score, and have blastoid variant. Response assessments were made using PET/CT. Out of 86 patients, 94% completed 6 cycles of RB/RC therapy. Off-trial patients (76%) were more likely to receive a lower starting dose (2 gm/m 2 or less) of cytarabine compared with trial patients (38%). Overall response rate and complete response rate were 98% and 92%, respectively, at the end of infusion.

Progression-free survival (PFS) for the entire cohort at 24 months and 48 months, respectively, were 88% and 80%; overall survival (OS) were 96% and 92%. PFS and OS were similar across cohorts with a trend toward inferior PFS in the higher-risk WUSTL cohort.

PFS was similar among off-trial patients treated at DFCI (32 patients) and in community centers (17 patients). In univariate analyses, PFS was not improved with a higher cytarabine dose (>2 gm/m 2), whereas blastoid or pleomorphic variant and high-risk MIPI score were associated with inferior PFS. Read more at http://bit.ly/2FKueV5.

Acupuncture Eases Some Self-Reported Symptoms of Cancer and Treatments

© KRISANAPONG DETRAPHIPHAT / GETTY IMAGES

Study results presented at the 2018 Palliative and Supportive Care in Oncology Symposium suggest that acupuncture may help provide relief from some symptoms of cancer and/ or cancer treatment.

In this study, 375 patients with canSymptoms assessed cer underwent acupuncture treatment with ESAS reports at a comprehensive cancer center’s outpatient integrative medicine clinic. Patients completed Edmonton Symptom Assessment Scale (ESAS) reports before and after acupuncture treatments. Scores were compared from baseline to the initial follow-up and before and after each treatment.

The mean number of acupuncture treatments was 4.6 (SD 5.1), with 73.3% of patients pursuing at least 1 follow-up

treatment. The most severe initial symptom scores related to pain, well-being, fatigue, and, especially, sleep.

With the first treatment, there were overall before/after improvements in all symptoms. The greatest mean symptom reduction was seen for hot flashes, and there were improvements also for nausea, numbness/tingling, and fatigue.

Global symptom improvement occurred from first treatment to initial follow-up, with a particular improvement in spiritual pain. Improvements in clinical response were greatest for nausea (57.3% of patients), dry mouth (57.8%), and spiritual pain (58.9%) after the first follow-up.

Read more at http://bit.ly/2R6aSLr.

Incidence of Adverse Effects of HEC for Breast Cancer Avoiding unnecessary inpatient and emergency room visits improves both patient care and reduces the cost of cancer treatment. According to the US Centers for Medicare and Medicaid Services (CMS), 20% of chemotherapy treatments cause adverse toxicities, including anemia, dehydration, diarrhea, fever, nausea, emesis, neutropenia, pain, pneumonia, or sepsis, that result in avoidable inpatient or emergency room visits. However, the rate of such events specifically in patients receiving highly emetogenic chemotherapy (HEC) for breast cancer has been understudied until now.

This study utilized a large electronic health record database to identify patients with breast cancer who received highly emetogenic chemotherapy between 2012 and 2017: 2304 patients received anthracycline + cyclophosphamide (AC), 1721 received carboplatin, and 103 received cisplatin.

Within 30 days of treatment 22% of patients receiving AC, 30% receiving carboplatin, and 23% receiving cisplatin had an inpatient or emergency room visit. Such visits were associated with 1 of the 10 CMS-defined toxicities for 73%, 72%, and 76% of patients receiving AC, carboplatin, and cisplatin, respectively.

Read more at http://bit.ly/2W6IqN0.

Common Reasons for Discontinuation of Oral Chemotherapy for Kidney Cancer Oral chemotherapy drugs have increased treatment options for patients with metastatic renal cell carcinoma (RCC);

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IN THE NEWS

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

Postmastectomy Breast Reconstruction Safe in Older Women Fewer than 14% of women ages 70 and older undergo postmastectomy breast reconstruction, largely because there is a concern that this older population may be more susceptible to postoperative complications. However, according to study results presented Outcomes similar to at the 2018 San Antonio Breast Cancer younger women Symposium, the likelihood of such complications in older women is extremely low.

The study utilized data from the National Surgical Quality Improvement database to identify 42,929 women who underwent breast reconstruction between 2005 and 2016, 2615 of whom were aged 70 or older. Women ages 18 to 69 were classified as young women. The authors compared the 30-day postoperative outcomes of these 2 groups.

Older women more commonly underwent immediate breast reconstruction (92% vs 88.3%), whereas young women were more likely to undergo delayed breast reconstruction (11.7% vs 8%). Older women did experience higher rates of superficial

surgical site infection (2.6% vs 1.8%) and urinary tract infection (0.6% vs 0.3%); but there was no significant difference between older and younger women in the rate of deep superficial surgical site infection, dehiscence, pneumonia, thromboembolism, renal complications, cardiac events, and sepsis. Interestingly, younger women were more likely to experience flap failure (2.1% vs 0.4%) and bleeding events requiring transfusion (1.8% vs 1%).

Both groups had similar rates of returning to the operating room within 30 days postreconstruction due to complications. Furthermore, the incidence of death at 30 days postreconstruction was extremely rare for both groups.

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

Radical Prostatectomy vs Active Surveillance: Results of Nearly 3 Decades of Follow-up Radical prostatectomy was associated with 2.9 years of gained life vs watchful waiting in patients with clinically detected, localized prostate cancer and a long life expectancy.

Nonetheless, both a high Gleason score and the presence of extracapsular extension in the prostatectomy arm were associated with a higher risk of death from prostate cancer.

This study sought to provide long-term follow-up to a randomized trial that compared radical prostatectomy to watchful waiting (ie, active surveillance). Researchers in Sweden randomly assigned 695 patients with localized prostate cancer to watchful waiting (348 patients) or radical prostatectomy (347 patients) between October 1989 and February 1999, collecting follow-up data through 2017.

By December 31, 2017, 292 patients (84%) in the watchfulwaiting arm and 261 patients (75%) in the radical prostatectomy arm had died. Of the deaths, 110 in the watchful-waiting arm and 71 in the prostatectomy arm were due to prostate cancer, with the relative risk of the prostatectomy arm at 0.55 (95% CI, 0.41-0.74; P < .001) and the absolute difference in risk at 11.7 percentage points (95% CI, 5.2-18.2).

The number needed to treat to prevent 1 death from any cause was 8.4. At 23 years post-radical prostatectomy, the average gain in extra years of life was 2.9.

Among the cohort of men who underwent radical prostatectomy, lesions with extracapsular extension were associated with 5 times the risk of death vs men with lesions without extracapsular extension. Additionally, in this cohort, a Gleason score higher than 7 was associated with a risk of death 10 times higher than in patients with a Gleason score of 6 or lower.

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

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however, many of these drugs are associated with adverse effects. A retrospective study assessed the reasons for dose reductions and treatment discontinuation in patients who received oral chemotherapy for metastatic RCC. The study included 124 patients with metastatic RCC who were prescribed oral chemotherapy at the Marshfield Clinic system. The drugs assessed were those approved by the FDA at the time of the study: sunitinib, sorafenib, pazopanib, axitinib, or everolimus.

The researchers reported 76 dose reductions in 36% of patients.

Common reasons for dose reduction included mucositis (17%), fatigue (13%), diarrhea (11%), and palmar-plantar erythrodysesthesia (11%). Mucositis was more commonly associated with sunitinib, fatigue with axitinib, diarrhea with pazopanib, and palmar-plantar erythrodysesthesia with sorafenib.

Among 116 patients, treatment was discontinued in 218 cases. The most common reasons for treatment discontinuation were fatigue (17%), palmar-plantar erythrodysesthesia (11%), diarrhea (7%), and nausea (7%). Two cases of hypothyroidism associated with sunitinib resulted in thyroid replacement therapy, and one case of hyperglycemia associated with everolimus also resulted in treatment discontinuation.

Lung Cancer-Specific Distress Screening Tool Not Needed But May Benefit Patients with lung cancer have higher reported levels of psychosocial problems compared with patients with other cancers. Although these patients cope with a range of psychosocial consequences, those consequences do not seem to be specific to lung cancer.

In this study, the consequences of lung cancer diagnosis and treatment were evaluated, with the objective of determining the need for a lung cancer-specific screening instrument to assess patient distress. The researchers held focus group meetings with patients undergoing various types of treatment for lung cancer to discuss their psychological and social experiences. Based on these discussions, the authors identified major themes that were then re-evaluated in a subsequent focus group.

Patient-reported psychosocial consequences included frustration due to physical limitation, fear of recurrence, sadness about leaving loved ones behind, and disappointment with social support. The most prominent concerns among patients was a fear of recurrence/metastasis as well as insecurity about the future. Insecurity about the future was most pronounced in patients receiving palliative treatment. All patients indicated a need for family support during treatment.

None of the themes were unique to lung cancer. However, the authors still recommend developing a lung cancer-specific screening instrument.

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

© JACOB WACKERHAUSEN / GETTY IMAGES

Mini-Pools of IVIG Just as Effective as Standard IVIG in Pediatric ITP Immune thrombocytopenia (ITP) leads to excessive bruising and bleeding as a result of low levels of platelets, the cells that help blood clot. Pediatric patients with ITP are typically treated with high levels of intravenous immunoglobulin G (IVIG), which contains plasma extracted from thousands of blood donations.

However, a recent study suggests that mini-pools of immunoglobulin created with as few as 20 donations are just as sufficient in treating pediatric ITP as standard high IVIG doses. The study included 72 patients, ranging in age from 1 year to 18 years, with newly diagnosed ITP and who had low platelet counts, but no serious bleeding. They were randomly placed in 3 possible treatment groups, each

containing 24 patients. Group A received 1 g/kg of minipool IVIG. Group B received standard IVIG treatment also at 1 g/kg. Group C received no platelet enhancing treatment.

Approximately 16.6% of patients in group A had a response, and 58.8% had a complete response. Comparably, in group B, 16.6% of patients had a response, and 66.6% showed complete response. Only 33.3% of patients in group C had a complete response. Group A patients had a response within 8 days, group B within 9 days, and group C within 21 days.

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

HNC Survivors Continue to Experience CSS at 1 Year or More Posttreatment Oftentimes cancer and its therapy may cause neuroinflammation and central sensitization, resulting in chronic systemic symptoms (CSS) such as fatigue, sleep disturbance, chronic widespread pain, mood disorders, neuropsychiatric symptoms, and temperature Diminished or poor QOL widely reported dysregulation.

For this study, a total of 155 head and neck cancer survivors who were at least 12 months posttreatment without cancer recurrence completed a onetime compilation of self-reported measures. The measures included the Vanderbilt Head and Neck Symptom survey plus the General Symptom Subscale, the Body Image Quality of Life Inventory, Neurotoxicity Rating Scale, the Profile of Mood States, and a 5-item quality of life measure.

One or more moderate-to-severe systemic symptoms were experienced by 48.4% of patients. Individual symptoms varied in frequency from 20% to 56%, with approximately half of patients experiencing moderate-to-severe symptom intensity.

Reported neuropsychiatric symptoms were also frequent and severe. Although body image was not negatively impacted, survivors had low profile of mood state scores.

Approximately 40% of head and neck cancer survivors reported a diminished quality of life, with up to 15% reporting poor quality of life. ■ Read more at http://bit.ly/2RJtLZz.

For full news stories visit OncologyNurseAdvisor.com

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NAVIGATOR NOTES How Culturally Competent Care Differs for Jewish Women With Breast Cancer Megan Garlapow, PhD

Resources supporting culturally competent care are available for clinicians, and the continuum of care can additionally include rabbis and other religious leaders of Judaism. “Nurses and nurse navigators can access cultural competency trainings and culturally sensitive resources through Sharsheret.

Additionally, local hospital chaplains and clergy are often trained in these resources,” explained Ms Fleischmann.

People of Ashkenazi Jewish ancestry may identify as secular or may practice one of many forms of Judaism. Orthodox Jews generally show the greatest adherence to religious law, and this may shape concerns they could have as patients.4 UNDERSTANDING UNIQUE BELIEFS

nurse navigators meet those needs,” Adina Fleischmann, LSW, director of support programs at Sharsheret, a national nonprofit organization supporting young Jewish women with breast cancer, told Oncology Nurse Advisor.

In a 2014 study comprising members of the Orthodox Jewish community in Detroit, Michigan, researchers identified a few elements of religious observance that these members described influencing their thoughts on health care.4 The notion of hidden miracles, or divine intervention operating in unseen ways, caused concern among some participants that taking actions such as cancer screenings may preclude the possibility of hidden intervention, because a disease would then become exposed to awareness.4 Study participants also expressed a sense of inevitability — a belief that screenings or preventive measures do little to change the course of one’s fate.

Some concerns related to high costs coupled with insufficient insurance, as well as prioritization; regular schedule demands, including preparing for

Orthodox Jews generally show the greatest adherence to religious law, and this may shape concerns they could have as patients.

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C

ulturally competent care is an approach to healthcare delivery that incorporates strategies for reducing cultural disparities in health care and can involve training, interpreter services, coordination with community leaders, and other techniques.1 Culturally competent care may be important to consider when dealing with populations that are more susceptible to certain medical conditions. One example of such a susceptibility is the relatively high prevalence of BRCA1 and BRCA2 mutations within the Ashkenazi Jewish population, which confers a greater risk of certain cancers, including breast cancer.2 According to the Centers for Disease Control and Prevention (CDC), 1 of every 40 Ashkenazi Jewish women carries a BRCA mutation, compared with a prevalence of 1 of every 500 women in the general population.2,3 The CDC also estimates that approximately 50% of women with a BRCA1 or BRCA2 mutation will develop breast cancer by age 70, compared with 7% of women overall in the United States.3 Although culturally competent care takes a patient’s cultural characteristics into account, each person is an individual who may deviate from cultural norms and whose individual values are paramount.

“Oncology nurses and nurse navigators need to know that there are many different ways that individuals and families relate to being Jewish — it’s not a onesize-fits-all! There are different ways to help Jewish patients feel most comfortable and there are resources developed to help oncology nurses and oncology

weekly Sabbath often taking precedence over a person’s own medical screenings.4 These study participants from the Detroit Orthodox Jewish community also mentioned issues of culturally appropriate, or kosher, communication and education, emphasizing modesty in language and behavior. The issue was raised within the group about whether, for instance, PAP smears fit within the confines of modesty.4 Also noted was a spiritual responsibility toward one’s health. However, while responsibility to take care of one’s health was expressed as a spiritual imperative, there was a concern that pursuing medical care may imply a lack of spiritual faith.4 General fear was mentioned as an obstacle to screening, which is not culturally unique, but members of the study community also explained that “cancer” is a term generally avoided out of fear, including a fear that mentioning the term could itself invite hazard.4 The role of one’s rabbi was noted as critical to the healthcare decisionmaking process for this community in terms of assistance with navigating many of the spiritual concerns that the participants raised.4 GENETICS AND COUNSELING

A 2016 study involving Orthodox Jewish thought leaders in Brooklyn, New York, also emphasized the role of the rabbi and other community leaders in consultation regarding healthcare decisions but hinted at shifting norms within the community concerning genetic testing and counseling.5 In this study based in Brooklyn, participants explained that fear of cancer was pervasive.5 Both study groups described a sense of inevitability toward a cancer diagnosis in addition to an inner debate around violating any plans of the divine vs the responsibility toward self-care.4,5

Genetic testing was described by participants in the Brooklyn group as being different in nature from cancer screenings; although cancer screenings provide actionable information for

“Ask your patients about their culture — let them be the experts!” dealing with active disease, the concern was that genetic testing may veer toward interference with the plans of the divine. However, some participants expressed a view that current medical technologies are tools made available by the divine to enable self-care.5 Participants in each study also discussed a stigma around being identified as carrying a higher cancer risk due to family history or genetic testing.4,5 The study participants in Brooklyn described a change in norms over time, with, for example, avoidance of the word “cancer” giving way to women more recently undergoing regular mammography and PAP smears. Concern over a possible stigma around cancer risk also appeared superseded by an openness to possibility around dealing with it.5

Ms Fleischmann emphasized the importance of healthcare providers initiating culturally competent conversations with their patients as soon as possible. “It’s important to have an open conversation about cultural needs from the outset to set the stage for a supportive relationship,” she explained.

Culturally competent care for Jewish women with breast cancer is, like so much of health care, improved by clear and open communication. “Ask your patients about their culture — let them be the experts! Find out what’s important to them, and ask how you can best meet their needs,” Ms Fleishmann concluded.

“Cultural competency is a journey — don’t be afraid to ask questions, and turn to your resources for support!” ■ Megan Garlapow is a medical writer based in Tempe, Arizona.

REFERENCES 1. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57 Suppl 1:181-217.

2. Jewish women and BRCA gene mutations.

Centers for Disease Control and Prevention (CDC) website. https://www.cdc.gov/cancer/ breast/young_women/bringyourbrave/ hereditary_breast_cancer/jewish_women_ brca.htm. Updated November 5, 2018. Accessed January 27, 2019.

CONCLUSION

The authors of the Brooklyn-based study emphasized the value of rabbinic consultation to their respective communities and recommended that professionals in the oncology community provide resources to rabbis to assist with guidance of community members.

They also urged patient care providers directly check with patients about their preferences, being careful not make assumptions based on cultural identity.5

3. BRCA gene mutations. Centers for Disease Control and Prevention (CDC) website. https:// www.cdc.gov/cancer/breast/young_women/ bringyourbrave/hereditary_breast_cancer/ brca_gene_mutations.htm. Updated November 5, 2018. Accessed January 27, 2019.

4. Tkatch R, Hudson J, Katz A, et al. Barriers to cancer screening among Orthodox Jewish women.

J Community Health. 2014;39(6):1200-1208.

5. BresslerT, Popp B. Orthodox Jewish thought leaders’ insights regarding BRCA mutations: a descriptive study. J Oncol Pract. 2017;13:e303-e309.

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FEATURE | Adverse-Effect Management

FMT Offers Promising Strategy Against ICI-Associated Colitis Two case reports demonstrate the potential effectiveness of fecal microbiota transplantation in resolving cancer immunotherapy-triggered colitis.

© STOCKTREK IMAGES / GETTY IMAGES / STEVE GSCHMEISSNER / SCIENCE SOURCE

ICI therapy can disrupt the healthy balance of bacteria and microbes (inset) in the colon.

BRYANT FURLOW

F

ecal bacteria appear to play important roles in colon inflammation (colitis) and tumor biology. A pair of case studies suggest that healthy-donor fecal microbiota transplantation (FMT) can resolve anticancer immune checkpoint inhibitor (ICI)-induced colitis. However, ICI colitis has clinical and histopathologic mimics and should be carefully differentiated from other colitis etiologies.

The 2 patients’ treatment-resistant ICIassociated colitis went into remission soon after endoscopic FMT, which was offered on a compassionate-use basis.1 “The resolution of colitis in these patients can be confirmed clinically and endoscopically after FMT,” explained lead study author Yinhong Wang, MD, PhD, MS, of the Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, in Houston. “Based on these encouraging results, this should be evaluated even as a fi rst-line therapy for ICI-associated colitis because it is safe, quick, and the effect is durable, from one treatment.”

The fi ndings suggest that earlier work on mouse models can be successfully translated to clinical benefits for human patients, Dr Wang told Oncology Nurse Advisor.

Immune checkpoint inhibitors counteract some tumors’ ability to slow antitumor immune response using the checkpoint mechanism through PD1 and CTLA4, offering sometimes dramatic tumor responses for a minority of

10 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2019 • www.OncologyNurseAdvisor.com

patients. But these agents are also associated with potentially serious immune-related adverse events (irAEs) such as immune-mediated colon inflammation, or colitis. Severe ICI-associated colitis can lead to significant morbidity and a halt in ICI therapy until colitis is successfully resolved. The development of treatment options for patients with immunosuppression (eg, corticosteroid)-refractory ICI colitis is therefore an urgently important task.

Patients who benefit from ICIs but who experience irAEs are being denied an effective, potentially life-prolonging treatment when that treatment is interrupted or discontinued. “We have a limited amount of time to fix the problem so they can resume ICI treatment,” explained Dr Wang.

Corticosteroid therapy can also diminish the efficacy of ICIs, and immunosuppressive treatment usually causes other comorbidities, such as Clostridium difficile infections, so firstline treatment of ICI colitis with FMT instead of steroids should be explored.

Donor fecal bacterial ecologies appear to remain fairly stable in recipients’ guts but over time they do evolve.

“There are a number of factors that could be involved in this process,” Dr Wang explained. “One is if a patient had to be exposed to antibiotics afterwards. Because sicker patients tend to get infections, they get antibiotics and that can potentially change their microbiome. Second, other cancer treatments have the potential to also affect the microbiome pattern. So, with time, microbiomes start to change from the initial [donor] combination of bacterial species.”

“Even though their microbiome patterns shifted away from donor [ecologies] a little bit after a few months, our patients’ clinical symptoms remained very stable,” she noted.

“They don’t have recurring symptoms. We found that a little surprising.”

However, when donated fecal ecologies change, Dr Wang added, it would “not be a big deal to perform another fecal transplant, if needed.”

Previous preclinical research has suggested that feeding fecal bacteria to mice with immune checkpoint inhibition might offer a synergistic effect on tumor regression. “That suggests certain gut bacteria species can play a big role in tumor regression,” she said.

The therapy is in its early stages and whether such benefits will occur in human patients is not yet clear, or if some cancers may be more responsive to FMT than others.

“At this point, we will treat patients who develop colitis no matter what type of cancer they have,” Dr Wang said. “As we get larger patient populations, I think we might be able to learn

about the roles of specific bacteria, and specific cancer types, and could find out if FMT will help with cancer regression as well as colitis.” Thus far, there’s no evidence of safety concerns.

“There is extensive research published on FMT for recurrent C difficile infection and inflammatory bowel disease, even in immunocompromised patients,” she said. “Studies showed consistent results of high efficacy in treatment outcome with minimal serious side effects.”

A 2017 systematic review and meta-analysis of data from 4 studies (representing 277 patients) had suggested that FMT improves remission rates for active ulcerative colitis, compared to placebo, without any significant increase in serious adverse events.2 FMT has also been proposed as a potential treatment for patients undergoing allogeneic hematopoietic cell transplant.3 Some researchers have introduced fecal material through feeding tubes, but that entails an aspiration risk when patients are heavily sedated or nauseated, cautioned Dr Wang. But her team used colonoscopic FMT, which entails only the risks related to routine colonoscopy.

Larger volumes of fecal material are deliverable through colonoscopy, as well. “That seems to be more effective than the smaller amounts they can deliver through the upper GI route,” she said.

“From the feedback from my nursing and technician team, we found doing FMT is very straightforward — it’s a simple procedure that you just need to go through standard protocol,” explained Dr Wang. “Patients who receive FMT need a close follow-up within a week to make sure there’s no adverse events. Otherwise, it’s an outpatient procedure and patients can go home right after the procedure.”

FMT is not yet FDA approved for routine clinical use except in the setting of recurrent C difficile treatment. The agency has determined that fecal material is a biological agent and that FMT must be regulated to protect patients.

“We need bigger sample-size studies,” Dr Wang points out.

“That’s our next step. I anticipate we will begin recruiting for a larger trial in the next 3 months. Obviously, there are a lot of factors involved to get this trial launched: we need to have our institution IRB [Institutional Review Board]

Immune checkpoint inhibitors have transformed the treatment of several advanced-stage cancers, but like any drug, they come with side effects.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2019 • ONCOLOGY NURSE ADVISOR 11

© LEWIS HOUGHTON / SCIENCE SOURCE

FEATURE | Adverse-Effect Management

Laboratoryprepared tryptic soy broth for FMT.

and an IND [Investigational New Drug authorization] from the FDA in place, and we need funding support.”

DIAGNOSTIC MIMICS ICI colitis and hepatitis must be accurately diagnosed for timely, optimal patient management, and other conditions can mimic these irAEs, cautioned Dipti Karamchandani, MD, associate professor, Department of Pathology, Penn State Milton S. Hershey Medical Center, in Hershey, Pennsylvania.4 Immune checkpoint inhibitors have transformed the treatment and prognosis of several advanced-stage cancers, but like any drug, they come with side effects. “As we expect increased use of these drugs in the near future, it is anticipated that more and more patients affected with irAEs will be encountered in clinical practice,” Dr Karamchandani explained.

When diagnosing ICI-associated colitis on biopsy, consider the histologic features in conjunction with the clinical history.

In addition, the clinical team should anticipate that irAEs can occur weeks or even months after ICI therapy ends.

“The common histopathologic findings encountered in colonic biopsies include an active colitis pattern of injury (neutrophilic cryptitis/crypt abscess) with increased apoptosis along with crypt atrophy/dropout, and apoptotic microabscesses,” Dr Karamchandani explained. “Dense,

predominantly lymphocytic infiltrate in the lamina propria with variably frequent plasma cells and eosinophils are seen.”

Another pattern of injury is lymphocytic colitis, which is characterized by increased intraepithelial lymphocytes with epithelial injury along with increased lamina propria inflammatory cell infi ltrates.

Recurrent ICI-induced colitis often entails signs of chronic mucosal injury, such as basilar lymphoplasmacytosis, significant crypt architectural distortion, Paneth cell, and/or pyloric gland metaplasia. “However, these histopathologic findings are not specific for ICI-therapy induced colitis,” cautioned Dr Karamchandani. “The most common histopathologic mimics — to name a few — include other drug-induced colitides, infections, and acute graft-versus-host disease (GVHD).”

Drugs that can yield a similar pattern of injury include mycophenolate mofetil [an immunosuppressive drug], antimetabolites such as fluorouracil or capecitabine, tumor necrosis factor (TNF)-alpha inhibitors, and the phosphoinositide 3-kinase-δ inhibitor idelalisib.

“Lymphocytic colitis pattern of injury can be seen secondary to multiple other medications, such as nonsteroidal antiinflammatory drugs, proton pump inhibitors, and histamine receptor inhibitors, among others,” added Dr Karamchandani.

“GVHD colitis may exhibit similar histological picture; however, a clinical history of stem cell transplantation vs ICI therapy may help confirm the diagnosis.”

Infection-associated colitis — particularly cytomegalovirus (CMV) colitis — can produce a similar histologic picture “and should always be considered with the above histology as patients receiving ICI therapy are immunosuppressed and inherently susceptible to opportunistic infections,” noted Dr Karamchandani. “Pathologists should have a low threshold for ordering CMV immunohistochemical stain in this setting.” ■ Bryant Furlow is a medical writer based in Albuquerque, New Mexico.

REFERENCES 1. Wang Y, Wiesnoski DH, Helmink BA, et al. Fecal microbiota transplantation for refractory immune checkpoint inhibitor-associated colitis.

Nature Med. 2018;24(12):1804-1808.

2. Narula N, Kassam Z, Yuan Y, et al. Systematic review and meta-analysis: fecal microbiota transplantation for treatment of active ulcerative colitis.

Inflamm Bowel Dis. 2017;23(10):1702-1709.

The clinical team should anticipate that immune-related adverse events can occur weeks or even months after ICI therapy ends.

3. DeFilipp Z, Hohmann E, Jenq RR, Chen YB. Fecal microbiota transplantation: restoring the injured microbiome after allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2019;25(1):e17-e22.

4. Karamchandani DM, Chetty R. Immune checkpoint inhibitor-induced gastrointestinal and hepatic injury: pathologists’ perspective. J Clin Pathol. 2018;71(8):665-671.

12 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2019 • www.OncologyNurseAdvisor.com

FEATURE | Complementary and Alternative Medicine

How Much Faith Do Patients Put in Alternative Medicines?

ASCO 2018 Cancer Opinions Survey examines the beliefs some patients have regarding the cure potential of alternative medicine practices.

BRYANT FURLOW

© SKAMAN306 / GETTY IMAGES

T

Patients’ beliefs in alternative medicine pose a challenge, and a threat, to providing evidence-based care.

hirty-eight percent of Americans surveyed — more than one in three — believe cancer can be cured using alternative or complementary remedies, according to the American Society of Clinical Oncology (ASCO), despite evidence that pursuing alternatives to evidencebased cancer treatment can reduce survival time.

An unknown number of patients pursue alternative remedies that might interfere with evidencebased treatment efficacy, and they rarely tell their cancer care team. Some delay evidence-based care, believing that the latest “cancer cure” seen on social media will cure their disease.

Patients encounter a potentially bewildering array of supposed miracle cures on social media, and more than one-third believe what they read.

Nearly 4 in 10 Americans surveyed said they believe alternative remedies can cure cancer, according to the ASCO 2018 Cancer Opinions Survey.1 Among younger Americans — 17 to 37 years old — 47% believe cancer can be cured solely through alternative remedies, without standard cancer treatment.1 By some estimates, as many as 8 in 10 patients with cancer use some form of alternative medicine, such as herbal or vitamin supplements, yoga, or acupuncture.2 “That percentage is astounding,” said Suzie Siegel, a gynecologic sarcoma survivor and patient advocate. “Cancer patients are inundated with advice, including a lot on alternative medicine.

One friend insisted that I try Ayurvedic medicine.”

Caterpillars of the Tibetan plateau ghost moth that have become encased in a parasitic fungus,

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2019 • ONCOLOGY NURSE ADVISOR 13

FEATURE | Complementary and Alternative Medicine Ophiocordyceps sinensis, are worth more than their weight in gold, thanks largely to the unevidenced but widespread belief that they can cure cancer.3 (Along with climate change, the resulting consumer demand and overharvesting appear to be driving the fungus extinct, according to a recent report.3) PRESSURE TO THINK OUTSIDE THE BOX Such beliefs can be downright dangerous. Far from curing cancers, use of alternative remedies is associated with an increased likelihood of refusing conventional, evidencebased care for curable cancers — and a higher risk of death.4 But social media platforms such as Facebook have given dubious claims about easy miracle cures a growing audience of patients and well-intentioned family and friends.

“Friends may recommend an alternative treatment on social media just as they might in person,” Siegel said. “The difference is that social media lets you hear from a multitude of friends in a short period of time, increasing the chances you’ll hear something crazy. People reading Twitter at random, for example, come across promotions of alternative “cures.”

Even some award-winning newspapers allow online ads that tout inaccurate health claims.”

The proliferation of predatory and pseudoscientific journals online has further blurred the boundaries between the scientifically credible and snake oil, online.5

Many patients do not know how to distinguish credible sources or evidence-based claims from marketing or outright malarky.

“I’ve talked to patients who were nauseated or losing weight because of strict diets or the number of supplements they were taking,” Siegel said.

Supposed herbal remedies for melanoma range from eggplant and frankincense to turmeric, black raspberry, milk thistle — and cannabis.6 CANNABIS AND OTHER “MEDICAL” PRACTICES The ASCO survey shows that 83% of Americans support cancer patients’ use of “medical” marijuana, even though cannabis’ illegality has precluded the maturation of a convincing evidence base for claimed antitumor effects.1 (Cannabis is also used by some patients as an antiemetic or appetite stimulant, but again: little empirical research is available.)

“I hear about cannabis and CBD oil nonstop,” Siegel lamented. “These definitely feed into the theory that the

government or the healthcare system does not want patients to have the ‘real’ cures. Truth is, the government hasn’t wanted people to use [illicit] drugs, including marijuana. But the government didn’t make marijuana illegal because it was a cure-all. I explain to people that the alternative-medicine market is worth millions, if not billions. Marijuana/CBD oil is quickly becoming big business.”

Ads on Facebook have touted CBD oil as a cure for advanced pancreatic cancer, despite the absence of any clinical trials or evidence base for such claims. Widespread misunderstandings, such as the belief that an alkaline diet can defeat cancer, can snowball or metastasize.

“Lemons for Leukemia” is a fundraiser like the ice-bucket challenge, but one patient saw it mentioned on her cancer center’s Facebook page and thought her doctors were encouraging patients to eat more lemons as part of an alkaline diet, Siegel said.

A man with synovial sarcoma of the jaw pursued naturopathic remedies for more than a year instead of the surgery his doctor recommended and wound up undergoing tracheotomy and needing a feeding tube, Siegel noted.7 IF YOU DON’T ASK, PATIENTS WON’T TELL But many patients do not know how to distinguish credible sources or evidence-based claims from marketing or outright malarky, Siegel cautioned. And patients rarely volunteer to their cancer care team that they are using alternative remedies.

“Patients should always be asked about alternative therapies, with the explanation that some can interfere with other treatments,” Siegel said. “Then nurses and doctors can discuss what might be harmful.”

“An open attitude helps,” she said. “After all, the people who promote alternative treatments are also feeding patients the conspiracy theory that healthcare professionals care only about money and don’t want patients to discover ‘true cures’.”

Siegel does peer-to-peer counseling and support work with other cancer patients. “Patients who choose to give up conventional treatment altogether don’t stay with me — they find somebody who will support their views,” Siegel added. ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico.

REFERENCES 1. ASCO 2018 Cancer Opinions Survey. October 2018. https://www.asco. org/sites/new-www.asco.org/files/content-files/research-and-progress/ documents/2018-NCOS-Results.pdf. Accessed January 27, 2019.

2. Brody JE. The risk of alternative cancer treatments. New York Times; October 1, 2018. https://www.nytimes.com/2018/10/01/well/live/therisk-of-alternative-cancer-treatments.html. Accessed January 27, 2019.

14 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2019 • www.OncologyNurseAdvisor.com

predatory publishing phenomenon. Cureus. 2018;10(5):e2617.

3. Yong E. The world’s most valuable parasite is in trouble. The Atlantic; October 22, 2018. https://www.theatlantic.com/science/archive/2018/10/

cancer [published online August 9, 2018]. Dermatol Surg. doi: 10.1097/

tibetan-caterpillar-fungus-trouble/573607/. January 27, 2019.

4. Johnson SB, Park HS, Gross CP, et al. Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers. JAMA Oncol. 2018;4(10):1375-1381.

5. Delgado-Lopez PD, Corrales-Garcia EM. Influence of Internet and social media in promotion of alternative oncology, cancer quackery, and the

6. Li JY, Jampp JT. Review of common alternative herbal “remedies” for skin DSS.0000000000001622 7. Kimble L. Man who lost half his face to tumor has new lease on life: I’m ‘so much more than just my exterior.’ People; July 21, 2017. https://people.com/bodies/tim-mcgrath-lost-half-his-face-to-synovialsarcoma-tumor/. Accessed January 27, 2019.

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JOURNAL REVIEW

C

linicians now have a better understanding of the ideal time in which to give vitamin B12 supplementation to patients receiving pemetrexed for the treatment of nonsmall cell lung cancer (NSCLC) or pleural mesothelioma. A new study published in the journal Clinical Lung Cancer has found that administering both on the same day appears to be a safe practice.1 “We did this analysis to resolve the practical question on the optimal timing of administering vitamin B12 and folate supplementation prior to starting pemetrexed. This was an area of some controversy,” explained study investigator Grace Dy, MD, division chief of Thoracic Oncology and associate professor of oncology in the Department of Medicine at Roswell Park Comprehensive Cancer Center, in Buffalo, New York. “Many clinical trials still require a 7-day wait time between vitamin B12 supplementation and administering pemetrexed, resulting in an extra week of delay in start of therapy.”

THE STUDY This single-center, retrospective study assessed the safety of administering B12 supplementation on the same day vs 1 or more days prior to pemetrexed infusion in patients with NSCLC or pleural mesothelioma. All the patients had new diagnoses and received pemetrexed 500 mg/m 2 with or without a platinum agent (cisplatin or carboplatin). Vitamin B12 dose was 1000 mg IM. Pemetrexed is a folate analog inhibitor currently considered a first-line therapy,

Safety of B12 Supplement, Pemetrexed Infusions on the Same Day John Schieszer, MA

with or without a platinum agent, for nonsquamous NSCLC and malignant pleural mesothelioma. Folic acid and vitamin B12 supplementation are required due to high rates of cytopenia.

However, data demonstrating optimal timing of supplementation is scarce.

Dr Dy and colleagues identified 281 patients (mean age 64.1 years): 137 patients received same-day B12 supplementation (same-day group) and 144 patients B12 supplementation at a median 7 days (range, 1 to 42 days) prior to pemetrexed infusion (prior group).

WHAT WAS LEARNED The researchers found that the mean changes in hematologic indices from cycle 1 (C1) to C2 or C2 to C3 did not differ significantly between the 2 groups. In addition, they found no significant differences in clinical events

between C1 and C2 or C2 and C3 where supportive care was required.

Treatment delays in C3 occurred in 24.6% of the patients in the same-day group compared with 11.9% in the prior group. The most common significant predictors of delay in C3 in the same-day group were baseline hemoglobin and absolute neutrophil count. Another common reason for delay in C3 was patient preference rather than medically related.

Overall, clinically meaningful changes in hematologic indices did not differ between patients based on the lead-in time of vitamin B12 supplementation.

However, the authors caution that there are inherent limitations to these findings due to this being a single-center retrospective study.

IMPLICATIONS FOR NURSES Same-day administration of vitamin B12 may facilitate earlier initiation of treatment. Clinical trials with pemetrexed currently stipulate administration of vitamin B12 at least 7 days before pemetrexed infusion. Based on these new findings, Dr Dy and colleagues recommend same-day vitamin B12 supplementation as a standard option in clinical trials utilizing pemetrexed, contending that this will help reduce unnecessary treatment delays. ■ John Schieszer is a medical reporter based in Seattle, Washington.

The reference for this article can be read in the online version, accessible through this easy link: https://bit.ly/JRNLR0219.

“Many clinical trials still require a 7-day wait time between vitamin B12 supplementation and administering pemetrexed, resulting in an extra week of delay in start of therapy.” — Grace Dy, MD 16 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2019 • www.OncologyNurseAdvisor.com

Write for ONA! Oncology Nurse Advisor offers clinical updates and evidence-based guidance to the oncology nurse community and includes regular coverage of topics such as the safe handling and administration of chemotherapy drugs, side effect management, new developments in specific cancers, palliative care, communication with patients and family, and cancer survivorship.

We welcome contributions from readers in the following categories: Oncology Nurse Advisor Forum: Answers to clinical questions and advice for clinical problems. Readers may submit questions and requests for advice that are 50 to 100 words long. The author should include full name and degrees, name of institution or practice, and city and state.

Feature article: Oncology Nurse Advisor welcomes feature articles on the administration and handling of chemotherapy drugs; side-effect management; communication with patients, families, and colleagues; whatâ&#x20AC;&#x2122;s new in the treatment of specific cancers or cancer-related conditions; survivorship issues; patient navigation; and other topics of interest to oncology nurses. Manuscripts should be 1200 to 2000 words long and should include a brief reference list.

Reflections: These are brief, reflective essays on a topic related to oncology practice or narratives recounting a meaningful experience with a patient. Manuscripts should be 800 to 1200 words long.

Case Study: This department focuses on clinical cases of interest to oncology nurses. Manuscripts should be written in the standard case-followed-by-discussion format and should be 1500 to 2000 words long. A brief reference list may accompany the discussion section. Please include a list of 3 to 5 take-home points (teaching points) for the reader. The PDF template in our Author Guidelines is an easy, step-by-step guide for writing up your Case Study.

Ask a Pharmacist: In this department, our oncology pharmacist answers readersâ&#x20AC;&#x2122; drug-related questions. Questions should be 50 to 100 words. The author should include full name and degrees, name of institution or practice, and city and state.

See our author guidelines, available at www.OncologyNurseAdvisor.com/ au-guides, for more details.

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RADIATION & YOUR PATIENT

Fertility Preservation Comes to the Forefront of Radiotherapy Bryant Furlow Advances in cancer care and delayed childbearing have yielded increasing numbers of cancer patients for whom fertility-preserving treatment options are a priority.

Communicating the fertility implications of radiation therapy and other cancer treatments should be standard practice at the time of diagnosis.

A

dvances in cancer treatment and reproductive technology have expanded the options for young women with cancer who wish to preserve their childbearing options, and young women with cancer are

now routinely counseled about the fertility implications of cancer and its treatment.1 More than 80% of children with cancer and 85% of those who are adolescents or young adults (AYA) during their cancer journey will survive.2 Of the anticipated 110,070 American women with new gynecologic cancer diagnoses this year, approximately 21% of them will be premenopausal at the time of diagnosis — younger than 40 years, typically.1 “Looking at cervical cancer specifically, 43% are younger than 45 years old,” said Nathalie D. McKenzie, MD, MSPH, an award-winning gynecologic oncologist at Florida Hospital Gynecologic Oncolog y, Florida Hospital Cancer Institute, in Orlando, Florida. “These women are also typically diagnosed at younger age — during those reproductive years.”

Those f igures, combined with increasing numbers of women who opt to wait until later in adulthood to have children, mean that a growing number of women receive a cancer diagnosis before they have had children.1 But treatment strategies can profoundly diminish survivors’ opportunities for childbearing and young women survivors have lower birth rates than do other women.2 Radiotherapy is associated with lower rates of female AYA cancer survivors who give birth (10%) than those who receive chemotherapy alone (18%) or surgery alone (44%).2 These trends forced changes in gynecologic cancer treatment paradigms, which traditionally had involved sterilizing treatments such as radiation fields that involved ovaries or the uterus, potentially inducing premature menopause.1 OPENING THE DISCUSSION

Patients value fertility counseling and there is evidence that it can reduce

patients’ later levels of regret and dissatisfaction, improving quality of life.1 There are not yet widely used, validated questionnaires to guide oncofertility discussions but the American Society of Clinical Oncology (ASCO) and other national organizations recommend such patient/clinician discussions as well as fertility referrals and consultations for patients of reproductive age at the time of diagnosis, “when all potential options can be discussed with the patient,” Dr McKenzie said.3 Fertility preservation options vary by cancer type, tumor location and stage, treatment history, and comorbidities.

Patient age is also relevant, when considering radiotherapy.

“Younger, when with more ‘reserve,’ are slightly more resilient on average,” explained Dr McKenzie. “The dose associated with 50% loss of fertility is lower closer to menopause than for very young women — those who are younger than 30, for example.”

Clinicians must convey to patients that even when fertility preservation is the goal and guides treatment decision-making, no one can be certain that fertility can always be maintained.

Intensity-modulated radiotherapy (IMRT) is increasingly used to spare radiosensitive nontarget reproductive tissues and to direct increased radiation doses to target tumors. But even IMRT cannot entirely eliminate the oocyte toxicity of pelvic radiotherapy, Dr McKenzie cautioned. Ovaries are so sensitive that even minimal doses of radiation can impact fertility for some women.

OTHER RISKS The odds of preterm, low-weight, or small-for-gestational-age births increase with radiation dose to the

18 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2019 • www.OncologyNurseAdvisor.com

uterus.1 Radiation dose to ovaries is directly correlated with the risk of subsequent infertility, due in part to increased risk of impaired pelvic blood flow.1 Lower doses of ionizing radiation to the ovaries, less than 2.0 Gy, can

Brachytherapy poses a lower risk to fertility but it is rarely used alone.

Chemotherapy agents used in chemoradiation regimens, particularly those involving alkylating chemotherapy with cyclophosphamide, ifosfamide, or busulfan-melphalan, can also cause ovarian toxicity.1 Platinum-based chemotherapy regimens involve a lower, moderate risk of gonadotoxicity, while methotrexate, vincristine, and bleomycin carry lower risks of gonadotoxicity.1 (Gonadotropin-releasing hormone analogue prophylaxis before chemotherapy might reduce the risk of premature ovarian failure.1)

Her group is developing an adjuvant radiotherapy strategy specifically for women who wish to undergo fertilitysparing surgery, but details are not yet available. ■

POTENTIAL RESOLUTIONS

2. Gerstl B, Sullivan E, Chong S, Chia D, Wand

Bryant Furlow is a medical journalist based in Albuquerque, New Mexico.

REFERENCES 1. McKenzie ND, Kennard JA, Ahmad S. Fertility preserving options for gynecologic malignancies: A review of current understanding and future directions. Crit Rev Oncol Hematol.

2018;132:116-124.

cause irregular menses but not necessarily sterility, whereas half of women receiving 2.5 Gy or higher radiation doses to the ovaries will experience persistent sterility.1 A dose of 20 Gy can induce premature ovarian function in younger women (younger than 40 years), whereas as little as 6 Gy can trigger premature ovarian insufficiency in older (older than 40 years), premenopausal women, Dr McKenzie noted.1

When radiotherapy is indicated, it is sometimes possible to surgically reposition the ovaries higher in the abdomen so that they are completely outside of the radiation field, Dr McKenzie said.

Oocyte and embryo cryopreservation are also widely available.3 Brachytherapy poses a lower risk to fertility but it is rarely used alone.

“This is not part of any current standard of care,” Dr McKenzie explained.

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H, Anazodo A. Reproductive outcomes after a childhood and young adolescent young adult cancer diagnosis in female cancer survivors: a systematic review and meta-analysis [published online December 5, 2018].

J Adolesc Young Adult Oncol. doi:10.1089/ jayao.2018.0036 3. Oktay K, Harvey BE, Partridge AH, et al.

Fertility preservation in patients with cancer: ASCO Clinical Practice Guideline update.

J Clin Oncol. 2018;36(19):1994-2001.

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COMMUNICATION CHALLENGES

A Call to Support Our Young Nurses

© GLOWIMAGES / GETTY IMAGES

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

In a so-called “caring” profession, why do we fail to care for those who are, professionally speaking, weaker?

In an article published April 14, 2017, Kathleen Colduvell, RN, BSN, BA, CBC, a staff writer for Nurse.org, referred to an article from 1986 in which nursing professor Judith Meissner coined the phrase “Nurses eat their young” as a call to action for nurses to stop ripping apart inexperienced coworkers.1

I

was in my intro to nursing class when I first heard the saying, “Nurses eat their young.” Just the image it elicited made me cringe. I had to stop for a second to figure out exactly what it meant in the realm of nursing. I thought of how some animals eat their young. But when animals eat their young, they do so because of scarce resources or it is unlikely to survive. How does the saying apply to nurses? The new-to-practice nurse/novice is inexperienced and may not be carrying his/ her weight. For experienced nurses, the lack of skills and reliability the novice demonstrates can lead to a level of frustration. This can translate into judgement about whether he/ she can succeed as a nurse.

The goal of this column isn’t to identify or describe the sociological phenomenon of nurses eating their young, but rather to address the areas that contribute to nurses’ challenges in communication. Often, when I think of communication challenges in nursing, I focus on the tough interactions with complex patients, their families, or other members of the healthcare team. Yet what of those interactions with other nurses, nurses with more experience who are purposely difficult? In a so-called “caring” profession, why do we fail to care for those who are, professionally speaking, weaker?

Articles about nurses eating their young focused on why it occurs and the bullying aspect of the phenomenon. Most included what might essentially be a call to arms: expert nurses needed to stop other nurses from bullying novice nurses, and in turn, novice nurses needed to stand up for themselves. The general theme was to encourage nurses to mentor the novice nurse, and to remember the times they were bullied. I have a clear memory of being a new grad and a charge nurse reducing me to tears over a relatively minor error. Right then and there I decided I would never make a new nurse feel the way I’d been made to feel.

But there are others who look at it as more of a rite of passage, that strength is drawn from adversity. The buck up theory. And yet …

In my role as a symptom nurse working with the palliative care team, my work day is spent moving between different nursing units.

I work in a community hospital, which means our oncology patients may be anywhere from ICU to the cardiac unit. As such, I interact with nurses from other specialties. I am struck by how often I will be asked a question, whispered to me as if it were a secret.

20 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2019 • www.OncologyNurseAdvisor.com

CASE I was on a regular med/surg unit to see a cancer patient we were following and greeted a nurse I knew had been working for a little more than a year. Many would have considered Stephanie to have exited the “new grad” phase of her practice. She leaned forward and glanced around before she whispered her question.

“Can I ask you a question?”

“Sure. What’s up?”

She pointed to one of the rooms. “Do you remember the patient who was in room 82?”

“Mr. Anderson? How is he?”

“He coded last night. I took care of him yesterday. I think I missed something.”

The communication challenge in this circumstance was twofold. Stephanie was asking for my input on how to address a specific nursing situation. She trusted me enough to be vulnerable in her practice, to say I’m not sure I handled things the best way. We walked through all of the pertinent information, her assessment, etc. All of the nursing stuff. I did not tell her what she did or failed to do; rather I guided her to an objective self-assessment and helped her draw her own conclusions about what she might have done differently.

She appreciated my input and would have left things there, but I knew there was more.

I asked how she felt, asked her to walk through her assessment of her feelings about the case. The forensic analysis of her nursing care was easier to tackle then the second part.

That was the bigger communication challenge. She felt a need to hide her professional vulnerability and was anxious over potentially being judged as incompetent. When a new grad is afraid to ask for help, is worried that he/she will be viewed as not good enough, not strong enough, then he/she is at greater risk of making mistakes and at greater risk of personal and professional distress and anxiety, even a greater risk of burnout.

good grades, my professors told me I was a great student and would be a great nurse. But when I started as a new grad and faced the complexity of doing the job on my own, I suddenly felt like I knew nothing. Transitions are difficult. In that most vulnerable time, support and mentoring is important.

I don’t think that Stephanie had been overtly bullied. I know enough of the staff on that unit to know that was unlikely. Instead she was looking for a mentor, someone to bounce things off of, to help her look at the situation objectively. When I started as a nurse, there were many nurses who had been in practice for 10 to 15 years or longer. But over the last 2 decades demographics have shifted. Fifteen to 20 years ago the workplace had opened up many other possibilities, and people moved away from pursuing nursing.

The middle layer of nurse mentors is thinner than when I started.

As I age, in life and in my nursing practice, I am more interested than ever in passing my knowledge along. I welcome the questions. I seek them out. I want to be seen as approachable. Mentoring is an essential part of passing our knowledge along.

In the end, it comes down to 2 concerns: one professional and one personal. On the professional level, I am proud to be a nurse and want to be sure the novice nurse is given the opportunities to grow into his/ her practice. And on the personal level, I want to ensure that the nurses I encounter are the best they can be. After all, who will take care of me someday when I am in a hospital? What will their skills be like if they haven’t been properly mentored? ■

After all, who will take care of me someday when I am in a hospital?

What will their skills be like if they haven’t been properly mentored?

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

REFERENCE 1. Colduvell K. Nurse bullying: stand up and speak out.

DISCUSSION When I was in nursing school I had a sense of knowing a lot, of being competent — I got

Nurse.org website. https://nurse.org/articles/howto-deal-with-nurse-bullying/. Published April 14, 2017. Accessed January 28, 2019.

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ISSUES IN CANCER SURVIVORSHIP © FOTOGRAFIXX / GETTY IMAGES

Cancer-Induced Cognitive Impairment, aka Chemo Brain, Gets a Novel Intervention Bette Weinstein Kaplan

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hemotherapy does great things for many types of cancer, but it can also do terrible things to the patients surviving those cancers.

Chemotherapy can make them vomit, and lose their hair. Patients may become fatigued, depressed, asthenic, anorexic, and nauseated even on good days … and then there is chemo brain — often referred to as cancer-induced cognitive impairment.

Studies show that 21% to 90% of patients report having experienced chemo brain, with symptoms sometimes lasting for up to 20 years after treatment.1 Diane Von Ah, PhD, first began investigating the fatigue experienced by women undergoing treatment for breast cancer when she was studying for her doctorate at the School of Nursing at the University of Alabama at Birmingham (UAB). Patients described having difficulty thinking clearly after having been treated with chemotherapy.

Approximately 20 years on, Dr Von Ah, as well as many other researchers, found that results of neuropsychological and subjective tests demonstrate that breast cancer survivors experience significant deficits in memory compared with women who did not have cancer.2 BRAIN EXERCISES EMERGE Neuroscientists have long been intrigued by the concept of brain plasticity — the ability of the brain to rewire itself. Michael Merzenich, PhD, a neuroscientist and

recipient of the Kavli Prize, the highest honor in neuroscience, discovered that plasticity is a lifelong phenomenon, and was the first to harness it when he coinvented the cochlear implant. He is also a pioneer in developing plasticitybased computerized brain exercises.

Through his studies on brain plasticity, Dr Merzenich developed computerized brain training exercises that could rewire the human brain through intensive adaptive practice, leading to a brain that is faster and more accurate — and as a result, has sharper cognitive abilities.

Dr Merzenich also founded Posit Science, a company dedicated to developing brain exercises that correctly implement the principles of brain plasticity. Fellow neuroscientist Henry Mahncke, PhD, led the development of the company’s global clinical trials team. To date, the team has had more than 100 peer-reviewed studies published showing the effectiveness of brainHQ, a series of cognitive training exercises based on brain plasticity.

Their work is now focusing on getting the science out of the lab and into the hands of the people it can help.

A number of independent academic scientists have also used the brainHQ exercises in their own clinical trials. In particular, Dr Von Ah, now at Indiana University, and colleagues and Janette Vardy, BMed(Hons), FRACP, PhD, and colleagues at the University of

Sydney conducted clinical trials — funded by the Robert Wood Johnson Foundation and the Clinical Oncology Society of Australia, respectively — using brainHQ exercises to see if this approach could help improve cognitive function in cancer survivors.

Both of these gold-standard, randomized, controlled trials demonstrated that cancer survivors, notably breast cancer survivors, demonstrated improvements in cognitive function, with broad improvements in quality of life, stress, depression, and other real-world concerns. Dr Von Ah’s study demonstrated that breast cancer survivors who practiced a specific set of 5 brain exercises in a group setting had improved core cognitive abilities, such as speed and memory, as well as improved general quality of life measures, such as stress and anxiety. Dr Vardy’s study showed that cancer survivors practicing the brain exercises in their own homes had improved cognitive function and less anxiety, depression, and fatigue.

Creative people often notice a change in cognitive function after cancer.

Because these patients tend to start from a relatively high level of cognitive function, they may still produce test results within the normal range for memory, attention, and speed. However, this does not accurately reflect the change from what had been their normal Continued on page 28

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THE TOTAL PATIENT © WENDY WEE / EYEEM / GETTY IMAGES

Integrative Medicine for Children: Practices That Can Help Pediatric Patients Bette Weinstein Kaplan

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hen a child is ill, especially with such a devastating disease as cancer, parents often feel desperate and helpless. There is so little they can do for their child, yet they want to be proactive in any way they can. Therefore, parents often consider complementary and integrative medicine practices.

Integrative medicine is def ined by the American Board of Integrative Med ici ne ® (A BOI M) a nd the Consortium of Academic Health Centers for Integrative Medicine as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing.”1 Integrative medicine incorporates complementary health approaches including mind and body practices as well as a variety of products and dietary supplements, such as herbs or botanicals, vitamins, minerals, and probiotics.2 Elena J. Ladas, PhD, RD, associate professor of nutrition (in Epidemiology, Pediatrics, and in the Institute of Human Nutrition) and director, Integrative Therapies Program at Columbia University Medical Center in New York City, investigated the use of integrative

and complementary medicine in pediatric patients with cancer.3 Incidence of childhood cancers has increased worldwide in the last decade, most likely as a result of heightened awareness and better access to treatment. Survival rates for children with acute lymphoblastic leukemia (ALL) is now more than 90%, while survival rates for all other childhood cancers are as high as 70%.3 To keep those numbers

Parents can learn proper [massage] techniques that will help their children. heading in a positive direction, practitioners should become familiar with the integrative and complementary medical interventions that are safe and effective in pediatric patients. Similarly, clinicians should be aware of treatments that raise concerns so they can educate anxious parents and offer alternatives.

INTEGRATIVE INTERVENTIONS Nutrition researchers have been study-

ing the role nutrition plays in the supportive care of pediatric patients with cancer. A 2016 meta-analysis of studies that included a combined total of more than 10,000 patients with ALL or acute

myeloid leukemia (AML) found that a higher body mass index (BMI) at diagnosis correlated with significantly poorer survival compared with those patients with a lower BMI.4 The adverse effects of the disease were ameliorated after initiating a dietary intervention that corrected poor nutrition, allowing for a better chance of survival. Those pediatric patients whose nutritional status remained either too low or too high experienced increased toxicity and decreased survival. Thus, clinicians can have a positive impact on pediatric patients’ outcomes through counseling patients and their families on healthful eating. This includes specialized diets such as neutropenic/low microbial diets that minimize the risk of infection and the ketogenic diet, which addresses the role of sugar in the growth of cancer.3 Diet and exercise The benefits of a proper diet and exercise extend to everyone. Such lifestyle interventions are proven to have a beneficial effect on lowering risk of cancer in adults.

However, data on whether pediatric patients experience similar benefits are limited, and studies are observational as opposed to interventional.

A study of 170 survivors of childhood cancer found that fatigue and quality of life were improved when national dietary guidelines were followed.

Other analyses found survivors who

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2019 • ONCOLOGY NURSE ADVISOR 27

THE TOTAL PATIENT continued to follow recommended diets participated in more physical activity and other healthy behaviors; however, cancer survivors are less active than their siblings or others in the general population. They are also less inclined to report enjoying leisure activities and other components of cancer prevention guidelines.3 Nutritional supplements Nutritional supplements can interact with conventional cancer treatments, making this a fraught subject. One recent study researched clinical trials using supplements for mucositis, toxicities of treatment and hepatotoxicity, appetite and weight management, neutropenia and fever, neuropathy, chemotherapyinduced nausea and vomiting (CINV), GI symptoms, and bone mineral density.

Although not all outcomes were positive, there were promising results for the use of glutamine and honey to treat mucositis, essential fatty acids to prevent weight loss, milk thistle to treat hepatic toxicity, and zinc for the prevention of infections and weight loss.3

Probiotics Although they are a fairly new area in childhood cancer treatment, probiotics hold some promise. A number of studies have shown that cancer therapy has a negative effect on the microbiome that is often compounded by antibiotic prophylaxis. Probiotics may be valuable in those cases, since current studies show their benefit for pediatric patients with diarrhea caused by antibiotics, chemotherapy, radiation, or Clostridium difficile.

Survivorship

interventions for evaluation through the NCI’s Research Tested Intervention Programs (RTIPs). The NCI program provides an important way to disseminate the results of academic science to health care providers and patients.

An independent clinical review resulted in the NCI designating brainHQ online brain exercises as an RTIP. The brain exercise intervention is now included in the NCI database of evidencebased cancer interventions and program materials for program planners and public health practitioners. Healthcare providers and patients who come to the NCI looking for the latest evidence-based practices can review clinical trial results that otherwise might have been buried in the scientific literature.3

Continued from page 26

functioning. The brain exercises can be a critical tool to help them get back to where they were before their illness.

ONCOLOGY ORGANIZATION RECOGNITION

As a result of the research, the Oncology Nursing Society (ONS) and the American Cancer Society (ACS) include cognitive training in their evidencebased guidelines for the treatment of chemo brain. After publication of the guidelines, the Posit Science team received an open request from the National Cancer Institute (NCI) to submit the evidence on their brain exercise

COMPLEMENTARY THERAPIES Acupuncture The National Cancer

Institute (NCI) published a white paper on the use of acupuncture in oncology that reported the practice as apparently safe for both adult and pediatric patients with cancer.5 The 2 clinical trials on the use of acupuncture for managing CINV in pediatric patients found it to be effective. Findings included significant decreases in vomiting and antiemetic use.3 Aromatherapy This review included one study on the use of aromatherapy in

children undergoing hematopoeitic stem cell transplantation (HSCT). Among 27 children with anxiety who were undergoing HSCT for several types of cancers, bergamot essential oil actually increased the patients’ anxiety and nausea compared with the control group.

Massage This beneficial and accessible practice can be learned from a licensed massage therapist. Parents can learn proper techniques that will help their children with cancer; it is cost effective and readily available. Adults with cancer also benefit from massage during their cancer treatment.

In conclusion, despite the benefits of many of these practices, Dr Ladas notes that more research on the use of integrative medicine in pediatric patients with cancer is needed. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

The references for this article can be read in the online version, accessible through this easy link: https://bit.ly/TtlPt0219.

The NCI RTIPS program is focused on ensuring that practitioners and patients can use evidence-based practices in real-world situations. As part of that process, there is a web page linked to the NCI describing how brainHQ was used in studies, with specif ic instructions and advice for health care providers who want to incorporate the program into their implementation of the ONS and ACS cognitive training guidelines.4 ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

The references for this article can be read in the online version, accessible through this easy link: https://bit.ly/Srvshp0219.

28 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2019 • www.OncologyNurseAdvisor.com

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oncepts of the wounded healer: universality of brokenness; dual nature of psychic and somatic wounding; healing as a shared process; interplay of humility, vulnerability, compassion, and joy in holistic care; shared suffering leads to wisdom and understanding.

The wounded healer hails from the beginning of Western medicine and speaks to holistic care or Asklepian treatment. Hippocratic medicine created a rift in holistic care producing a separation between mind (psych) and body (soma). To this day, in most medical schools, Asclepius remains in the Hippocratic Oath.

For healthcare workers, especially nurses and doctors, this separation created a hierarchy where roles of healer and patient are strictly defined, and the shared humanity found in suffering is cut off. The wounded healer, exemplified by the Greek myth of Chiron, informs us how our shared suffering can open the door to compassion and empathy, allowing holistic care of oncology patients by understanding the physical and psychological suffering of each.

Much of nursing is working by hand.

The role of touch in healing, not just physical touch, allows oneself to touch and be touched emotionally, at the heart level. It is often in silence, in the vulnerable space of not knowing the answer, that the door can be opened to healing and transformation in the clinical encounter.

By being aware of one’s own woundedness — including the wound of our

The Role for Wounded Healers in Oncology Nursing Richard Dickens, MS, LCSW

mortality — we can be more effective healers in our work as healthcare professionals. Adopting the stance of the wounded healer means that the clinical relationship is 2-way: we both heal and are healed by our patients. Allowing oneself to be wounded and vulnerable can actually be healing to patients.

Doctor and best-selling author, Rachel Naomi Remen, MD, struggled with Crohn’s disease and its impact on her life. In My Grandfather’s Blessings, she wrote, “Over forty-seven years of illness I have been helped and fixed by a great number of people. I am grateful to them all. But all that helping and fixing left me wounded in some important and fundamental ways. Only service heals.… The best definition of service I have come across is a single word: Belonging. Service is the final healing of isolation and loneliness. It is the lived experience of belonging.”1 In The Wounded Healer, author and theologian Henri Nouwen wrote, “Making one’s own wounds a source of healing, therefore, does not call for a sharing of superficial personal pains, but for a constant willingness to see one’s own pain and suffering as rising from the depth of the human condition that we all share.”2 Further on he writes, “It is healing because it takes away the false illusion that wholeness can be given by one to another. It is healing because it does not take away the loneliness and the pain of others, but invites them to recognize their loneliness on a level where it can be shared.”2 Martin Buber, professor and Jewish philosopher, best captured this pain of loneliness in his book I and Thou. “’I’ of ‘I and thou’ is different from the ‘I’ of ‘I and it.’ ‘I’ of ‘I and it’ lives within roles, tasks, and preoccupations that define us as separate individuals. These markers of individuality often function defensively, protecting us from a full awareness of our dependencies and

The wounded healer informs us how our shared suffering can open the door to compassion and empathy.

30 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2019 • www.OncologyNurseAdvisor.com

interdependencies as human beings.

The ‘I’ that speaks to ‘Thou’ has moved out from behind those barriers and — at the moment — lives in openness and vulnerability of relationship.”3 Without I/Thou the healer runs the risk of inflation, of seeing themselves as all knowing, and the wounded person, the patient, is only sick with no capacity to heal. Any deviation from or threat to the authority of the healer is seen as being noncompliant. The wounded person likewise invests all their hope and faith in the healer, seeing themselves as only wounded and does not see their own power as a healer. It’s like 2 literal poles, with wounded on one side and healer on the other. If both parties to the clinical encounter are holding both ends of both poles, the circuit is complete and the wounded healer archetype is activated.

Operating this way, from a place of weakness and solidarity, can provide a powerful buffer against burnout and compassion fatigue. It requires an understanding that when the archetype is activated, the healing does not come from us as clinicians but from some other source, from an unconscious process going on between us and the people who come to us for help.

The opposite of infl ation is overidentification with the patient’s own wounds, which can lead to feeling overwhelmed and burnout. Here is where the clinician can become harmed, and

Allowing oneself to be wounded and vulnerable can be healing to patients. it is part of the rationale for maintaining strong professional boundaries.

That is why maintaining self-care is so important. In addition to supervision, nurses might consider journaling, dream work, mindfulness, psychotherapy, prayer, and exercise as a way of becoming more conscious of wounds or at least more aware of their inner process and own inner-healer.

In closing, Vincent Corso, M.Div, LCSW, identifies ways to train wounded healers in health care: “One’s awareness of brokenness and mortality becomes a powerful tool when tending to the pain of another.… The author noticed that many effective nurses have a sense

of their own brokenness and connectedness to others, allowing them to be both healers and companions to the sick and dying. Their success is built on outcomes from good supervision, professional education, and psychotherapy.

A nurse’s commitment to the practice of self-care can be an advantageous means of maintaining personal and professional boundaries. Such practices allow nurses to truly be present with their patients without being completely overwhelmed by the painful complexities before them. Internal resources cannot be taken for granted.”4 ■ Richard Dickens is the director of Client Advocacy for CancerCare.

REFERENCES 1. Remen RN. My Grandfathers Blessing: Stories of Strength, Refuge, and Belonging. New York, NY: Riverhead Books; 2000:199-200.

2. Nouwen HJM. The Wounded Healer: Ministry in Contemporary Society. New York, NY: Image Books; 1979:94-95,98.

3. Buber M. I and Thou. New York, NY: Scribner; 1958.

4. Corso VM. Oncology nurse as wounded healer: developing a compassion identity.

Clin J Oncol Nurs. 2012;16(5):448-450.

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ASK A PHARMACIST

Preinfusion Amino Acid Solution; InjectionSite Pain What is the importance of the amino acid solution given before lutetium Lu 177 dotate (Lutathera®)? What is the difference between using a specially compounded or a standard (commercially available) solution?

— Name withheld on request

Lutetium Lu 177 dotatate is a radiolabeled somatostatin analog used in the treatment of certain neuroendocrine tumors. Many precautions are associated with its use, one of which involves use of an amino acid solution.

An amino acid solution containing L-lysine and L-arginine at specific concentrations (see the full prescribing

information for these details) must be infused starting 30 minutes prior to administering lutetium Lu 177 dotatate and continuing until at least 3 hours after the infusion is complete. The purpose of this solution is to prevent nephrotoxicity, as lutetium Lu 177 dotatate distributes to and is cleared through the kidneys.

Using an appropriate amino acid solution reduces the radiation dose to the kidneys by an average of 47%, thus reducing the potential for kidney damage.

Nausea is another adverse effect of lutetium Lu 177 dotatate, occurring in 65% of patients (vomiting occurs in 53%).

Estimates of up to two-thirds of the nausea and vomiting reported in some studies was due to the use of a commercially available amino acid solution. If it is not possible to obtain a compounded amino acid solution, escalating the antiemetics used may be prudent to better manage patients’ nausea and prevent vomiting.

What options are available to minimize the pain associated with goserelin (Zoladex) injections, given the recent shortage of sterile lidocaine for injection?

— Name withheld on request

Some institutions standardly administer lidocaine to numb the injection site prior to subcutaneous injection of goserelin.

Two small studies in Japan investigated use of goserelin in men with prostate cancer. The patients received one goserelin injection with no intervention and

one injection after undergoing numbing with an ice pack (applied for one-half to 2+ minutes). Both studies showed significant reductions in injection pain when patients underwent numbing prior to the injection.

Based on this information and recommendations from the manufacturer, numbing the injection site with an ice pack is a reasonable option to minimize pain.

I have looked in several sources for information on adjusting the dose of etoposide in a patient currently taking Prezcobix. Do you have any resources that give specific guidelines?

— Name withheld on request

Prezcobix (darunavir/cobicistat) inhibits CYP3A and CYP2D6, enzymes responsible for metabolism of many other medicines. When reviewing drug-drug interactions, I always like to use multiple references to ensure I obtain information that is as complete as possible. Evaluating these interactions can be difficult, particularly when changing either therapy is clinically difficult.

In cases where good alternate treatment options are not available, the patient should be involved in the risk:benefit conversation. Dose adjustments should also incorporate other patient characteristics, such as low albumin (which increases the proportion of unbound etoposide, increasing toxicity). ■

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

32 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2019 • www.OncologyNurseAdvisor.com