ONA March/April 2019

March/April 2019

www.OncologyNurseAdvisor.com 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

ADVERSE EVENT MANAGEMENT FEATURE

Adjusting Cancer Treatments for the Nonfrail Elderly

FROM CANCERCARE

Changes in Patients’ Needs After a Cancer Diagnosis

RADIATION & YOUR PATIENT

ASTRO/ASCO/AUA Guidelines for Hypofractionated Radiation Therapy for Prostate Cancer

COMMUNICATION CHALLENGES

Guide Dogs and White Canes

ISSUES IN CANCER SURVIVORSHIP

Recipes for Eating Healthy During Cancer Treatment

ASK A PHARMACIST

Pregnancy Screening During Chemotherapy

Nausea and Vomiting: Managing a Debilitating Effect of Treatment Inconsistent and lacking guidelines challenge effective management of treatmentinduced nausea and vomiting.

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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), March/April 2019, Volume 10, Number 2. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. Copyright © 2019. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

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

www.OncologyNurseAdvisor.com • MARCH/APRIL 2019 • ONCOLOGY NURSE ADVISOR 1

CONTENTS 4

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March/April 2019

IN THE NEWS • Bias Shown Toward Cervical Cancer Diagnoses • Nurses Weigh In on Patient-Centered Communication Practices • Analysis of AML in Elderly Shows Benefit of Decitabine Treatment in a Real-World Setting • Lymphoma Survivors Have Special Needs During Transition to Survivorship Care • Knowledge Benefits of SCPs Limited Among Early-Stage Breast Cancer Survivors

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• Patients Report on Benefits of Adherence to an ERP Following Colorectal Surgery • Use of Medical Disability Leave Due to Symptom Burden High With MPNs • Oncofertility Program Improved Knowledge of, Access to Fertility-Preservation Options • Primary Histologic Subtype an Independent Predictor of Melanoma Survival

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ONCOLOGY NURSE ADVISOR FORUM • Sharing Personal Contact Information With Patients • Caution Regarding Use of Buretrols

29 FIND US ON

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NAVIGATOR NOTES Influences on Decision to Use PCI for SCLC Brain Metastases Megan Garlapow, PhD

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JOURNAL REVIEW Adverse Events in Randomized Clinical Trials for Targeted Therapies High in Placebo Groups

Researchers conducted a meta-analysis to determine the incidence of adverse events among patients assigned to placebo-receiving groups in randomized clinical trials John Schieszer

FEATURES 15 Managing CINV and RINV: A Review of the Guidelines Bryant Furlow

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Adjusting Treatments for the Nonfrail Elderly With Cancer Bette Weinstein Kaplan

FROM CANCERCARE The Role of Positive Psychology in Oncology Practice

This novel way for patients — and nurses — to approach challenges can improve their mood and coping ability during a cancer crisis.

Claire Grainger-Valvano, LCSW, OSW-C

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RADIATION & YOUR PATIENT Joint Guideline Issued for Abbreviated RT for Prostate Cancer Bryant Furlow

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COMMUNICATION CHALLENGES Guide Dogs and White Canes

ISSUES IN CANCER SURVIVORSHIP Helping Patients Face the Challenge of Eating Healthy During Cancer Treatment Bette Weinstein Kaplan

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FROM CANCERCARE Supporting Changes in Need After a Cancer Diagnosis A.J. Cincotta-Eichenfield, LMSW

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ASK A PHARMACIST Pregnancy Screening During Chemotherapy Lisa A. Thompson, PharmD, BCOP

Identifying Support Needs for Caregivers, Patients With Colorectal Cancer

Researchers sought to identify the support networks for patients with colorectal cancer.

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

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THE TOTAL PATIENT

Bette Weinstein Kaplan

FACT SHEETS Prostate-Specific Antigen (PSA)

This fact sheet answers questions about the PSA test and its uses, limitations, and related research.

PUBLISHERS’ ALLIANCE: DOVE PRESS Trends in the Incidence, Treatment, and Survival of Patients With Lung Cancer in the Last Four Decades

Researchers report on trends in incidence, treatment, and survival of the disease over the last 40 years.

Cancer Management and Research

ON THE

WEB

www.OncologyNurseAdvisor.com • MARCH/APRIL 2019 • ONCOLOGY NURSE ADVISOR 3

IN THE NEWS Bias Shown Toward Cervical Cancer Diagnoses Recent evidence suggests that more negative perceptions are associated with a diagnosis of cervical cancer compared with ovarian cancer. This study was conducted to evaluate implicit emotions and beliefs, as opposed to self-reported explicit emotions and beliefs, of gynecologic healthcare providers regarding diagnosis of cervical vs ovarian cancer.

In this study, the Implicit Association Test (IAT) was administered online to healthcare providers recruited through membership in specific professional organizations. The IAT takes into account reaction times or error rates to assess relative associations, in this case between cervical cancer and ovarian cancer. An IAT implicit bias “d-score” of 0 was interpreted as a neutral association, whereas positive d-scores were considered to indicate implicit bias.

Of the 151 respondents included in the study analyses, 61.6% were physicians and 38.4% were nurses; 74.1% were female; and mean age was 39 years, with an average of 12 years in practice.

The overall group of respondents showed significant levels of implicit prejudice and stereotyping toward patients with cervical cancer. The mean score for implicit prejudice (standard deviation) was 0.17 (0.47) and 95% confidence interval (CI), 0.10-0.25; the mean score for implicit stereotyping was 0.15 (0.42); 95% CI, 0.08-0.21.

When evaluated separately, significant levels of implicit prejudice and stereotyping were observed among nurses but not among physicians. When results were evaluated according to sex, only women showed significant levels of implicit prejudice and stereotyping. In addition, older respondents and those with more years in practice exhibited stronger implicit prejudice and stereotyping toward patients with cervical cancer. Those clinicians with no training in cultural competency had greater bias than those who had received such training (P <.05).

Nurses Weigh In on Patient-Centered Communication Practices The increasing complexity of oncology care underlies the growing need for effective oncology nurse-led patient communication on a wide range of topics. These topics include patient-centered discussions related to prognostic information at diagnosis and disease recurrence, bereavement, and end-of-life issues, as well as survivorship care planning. In addition, barriers to effective patient communication, such as conflicts between family members or multidisciplinary team members, need to be identified and addressed.

Oncology nurses completed a survey prior to attending a COMFORT Communications training course, a National

Cancer Institute (NCI)–supported program focused on educating oncology nurses about communicating with patients on issues related to palliative care.

The 3-part survey queried oncology nurse participants about: • Communication practice standards at their institutions, • The content of communication training courses currently available at their institutions, and • Their perceptions of patient communication at their institutions.

The survey was completed by 355 nurses from a variety of cancer care settings in 42 states and Washington, DC. Across institutions, oncology nurses reported that patient communication was least effective during “bereavement,

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Read more at http://bit.ly/2UG4oFK.

when facing end-of-life, and through survivorship.” They also reported high levels of difficulty in communicating with patients when conflicts existed between patients and families or between members of the oncology care team.

Regarding the delivery of prognostic information or “bad news,” the majority of nurses reported being present for these discussions, but not leading them.

a response (22.6 vs 5.7 months). Although decitabine was generally well tolerated clinically, grade 3 or higher hematologic adverse events occurred in more than 90% of patients, although these were observed to diminish after 4 cycles of treatment. Common nonhematologic adverse events included infections, such as pneumonia and fever of unknown origin.

Read more at http://bit.ly/2u6vk5y.

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

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Analysis of AML in Elderly Shows Benefit of Decitabine Treatment in a Real-World Setting Despite the fact that acute myeloid leukemia (AML) most commonly occurs in older patients, decisions related to first-line treatment, as well as the treatment of relapsed/ refractory disease, are often complicated. The high frequency of organ dysfunction, poor performance status, unfavorable cytogenetics, and multidrug-resistant disease are some of the reasons underlying the poor outcomes and limited availability of treatment options for older patients with AML. Intensive chemotherapy, the standard-of-care for younger, healthier patients, is often not considered for these patients.

Results from an open-label, phase III randomized clinical trial comparing decitabine with physician choice of supportive care or low-dose cytarabine as first-line treatment of newly diagnosed AML in older patients have previously shown improved response rates for decitabine compared with the latter options, with similar safety profiles for these approaches. Nevertheless, questions remain regarding the risks and benefits of decitabine use for older patients with AML in a real-world clinical setting, for patients with either newly diagnosed or relapsed/refractory disease.

One hundred and four patients, median age 72.5 years, were included in this retrospective analysis. Baseline disease-related features confirmed the presence of unfavorable prognostic factors in this group, such as secondary AML (43% of patients), bone marrow blast cells higher than 30% (64%), and grade 3 or higher cytopenia (76%), although only 16% of patients had an Eastern Cooperative Oncology Group (ECOG) performance status greater than 2. Decitabine was administered as first-line and salvage therapy in 72% and 29% of patients, respectively.

The overall response rate (ORR) for older patients receiving first-line decitabine was significantly better compared with the ORR for those receiving this drug in the salvage setting (42% vs 14%). In addition, median overall survival in the complete cohort was significantly longer for patients achieving

Lymphoma Survivors Have Special Needs During Transition to Survivorship Care Most studies investigating the perspectives and experiences of cancer survivors have been carried out in solid tumor settings; therefore, evidence that the needs and concerns of survivors of hematologic malignancies may differ in some ways is limited.

Returning to work Patients aged 18 or older who had was a main concern completed intensive treatment for lymphoma between 3 and 60 months prior were invited by letter to participate in a descriptive qualitative study. Of 64 patients, 14 agreed to phone interviews.

In addition to demographic information, interview questions focused on patients’ feelings and opinions regarding completion of active treatment and their experiences during the end-of-treatment visit, if one was conducted. Responses were audio-recorded.

Five main themes emerged when patients’ responses were analyzed, centered on the following areas: dealing with uncertainty, changed relationships, returning to work, extended recovery times, and concerns for the future.

Responses were mixed regarding preparation for treatment cessation. For example, those respondents who had received intensive primary chemotherapy were more likely to encounter challenges due to the absence of monitoring by the treatment team. Respondents expressed concerns related to returning to work, citing immune deficiency and fatigue as their main barriers. Weight gain was another concern expressed by some participants. However, some reported improved interpersonal relationships. Most were in favor of receiving a written or electronic summary of treatment and survivorship care from a nurse specialist at a dedicated visit.

Read more at http://bit.ly/2F9khim.

In the News continues on page 6

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IN THE NEWS

A report issued in 2006 by the Institute of Medicine titled From Cancer Patient to Cancer Survivor: Lost in Transition included the recommendation that each cancer survivor should receive an individualized survivorship care plan (SCP) that includes details related to his or her cancer diagnosis and treatment, as well as recommendations for follow-up care to monitor and maintain health. However, most studies that have evaluated the benefits of SCPs have been small and/ or without a control group.

For this study, 127 patients with early-stage (0-III) breast cancer from 2 cancer centers received individualized SCPs at baseline or 4 weeks (delayed). Two surveys — the modified Wisconsin Survey of Cancer Diagnosis and Management in Breast Cancer and the Preparing for Life As a New Survivor survey — were used to evaluate how knowledgeable patients were on issues related to individual diagnosis and treatment, relevant treatment-related side effects, as well as how satisfied they were with their current care. The surveys were administered at baseline, and at 4 and 12 weeks. For patients in the delayed arm, administration of the surveys at 4 weeks occurred prior to receipt of the SCP. The primary outcome of the study, change in knowledge at 4 weeks, was not met when the two arms were compared.

The authors speculated that improvement of knowledge at 12, but not 4, weeks from baseline for the overall group was likely related to multiple administrations of the survey.

Read more at http://bit.ly/2VWTP14.

Patients Report on Benefits of Adherence to an ERP Following Colorectal Surgery Patients included in this study had been enrolled in a large randomized trial that previously demonstrated an association between adherence to an early recovery program (ERP) following colorectal surgery and postsurgical recovery as assessed using traditional clinical end points; however, these measures did not evaluate patient assessments of recovery.

In this study, assessments of patients’ adherence to the ERP were obtained from data collected within the randomized controlled trial. Postsurgical recovery from the perspective of patients was evaluated using 5 patient-reported outcome measures (PROMs): the Abdominal Surgery Impact Scale (ASIS) and the Multidimensional Fatigue Inventory (MFI20), which are designed to evaluate short-term recovery; and

the RAND-36 Physical and Mental Summary Scores, the Duke Activity Status Index, and the Life-Space Mobility (LSM) Scale, which assess long-term recovery.

Self-reported recovery assessments were obtained from 100 adult patients undergoing colorectal resection at a university hospital in Canada. Median adherence to the ERP, a structured multimodal approach to surgical care was 80%. The only interventions significantly associated with improved PROM scores were adherence to perioperative PONV prophylaxis and an early solid food diet. Adherence to specific ERP components was not associated with improved PROM scores measured at 4 weeks following surgery.

Read more at http://bit.ly/2u6MK26.

Use of Medical Disability Leave Due to Symptom Burden High With MPNs Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs; myelofibrosis, polycythemia vera, essential thrombocythemia) are associated with survival deficits, as well as a wide range of symptoms, including fatigue, bone pain, and night sweats, Thrombotic events that can be debilitating. Although often prompt MDLs results from previous studies suggest that a high symptom burden is negatively associated with employment status, the authors of this study wrote that “how MPN symptoms relate with medical disability leave among patients with the disease has not been previously examined.”

For this cross-sectional study, 904 patients with MPN who were employed at the time of diagnosis completed the Living with MPNs survey online. Of these patients, 49.5% reported taking no medical disability leave (MDL) and 24.8% reported taking one or more MDLs. The remaining patients (25.7%) reported other changes in employment status, such as early retirement or a reduction in work hours, and were not included in subsequent study analyses.

Patient- and disease-related characteristics were similar in the 2 study groups. However, those who reported taking MDLs were approximately twice as likely to have had a thrombotic event (31.3% vs 15.4%). Their mean age was 52.3 years, and they took their first leave 2.3 years after diagnosis.

In addition, 29.9% of the patients reported taking at least 2 MDLs, with nearly two-thirds of them not returning to work.

Read more at http://bit.ly/2Ja2SKp.

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Knowledge Benefits of SCPs Limited Among Early-Stage Breast Cancer Survivors

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Oncofertility Program Improved Knowledge of, Access to Fertility-Preservation Options In this study, a pilot oncofertility program was set up between the Regional Cancer Centre Northwest (RCCN) at the Thunder Bay Regional Health Sciences Centre in Thunder Bay, Ontario, Canada, and Mount Sinai Fertility (MSF) in Toronto, a fertilMost physicians said ONN was a key factor ity center almost 1400 km away from RCCN. Critical to the program was the development of a multidisciplinary oncofertility team between the two sites and the use of telemedicine. The multidisciplinary team included an oncofertility nurse navigator (ONN) and a gynecologist with expertise in oncofertility at RCCN who were trained at MSF, and endocrinology and fertility specialists, as well as an oncofertility nurse practitioner at MSF who had regular contact with the team members at RCCN. Women of reproductive potential at RCCN were identified for the program by the ONN who then provided initial fertility preservation counseling to the patient and her physician. For those patients wishing to further pursue fertility preservation options, the ONN would arrange an urgent remote teleconference between the patient and her care team and specialists at MSF. The ONN would also arrange appointments with a local gynecologist and specialists at MSF for those patients who choose to undergo fertility preservation procedures.

Pre- and posttreatment questionnaires related to fertility issues were completed by 22 women of reproductive age undergoing treatment at RCCN between February 2016 and January 2017. Sixty-eight percent of the women indicated that they did not want (more) children; 4 women, all of whom were nulliparous, participated in a fertility preservation teleconference with MSF specialists, 2 of whom traveled to MSF to undergo a fertility preservation procedure.

Questionnaires on experience with oncofertility and the pilot program were completed by 12 RCCN physicians before (pre-) and after (post-) the program. One preprogram questionnaire was excluded because more than half the questions were not answered, and one postprogram questionnaire was excluded because the respondent was not a physician. The 11 preprogram and 11 postprogram questionnaires included in the evaluation were not completed by all the same physicians at the 2 time points because of physician turnover and participation.

Physician responses indicated that 27.3% of respondents always or often discussed fertility concerns and fertility preservation options prior to the program; this increased to 72.7% of physicians responding to the postprogram questionnaire. Physician

responses indicated a high level of consensus regarding the benefits of the oncofertility program, with 89% agreeing that the addition of the ONN to the multidisciplinary team improved access to services related to fertility preservation.

Read more at http://bit.ly/FvED4v.

Primary Histologic Subtype an Independent Predictor of Melanoma Survival Shorter survival times associated with nodular melanoma (NM) compared with superficial spreading melanoma (SSM) have been well documented. This finding has often been attributed to an increased risk of metastasis associated with the increased thickness and likelihood of ulceration observed in NM. The belief that melanomas of different histologic subtypes behave similarly once they metastasize is common.

To investigate whether melanoma histologic subtype is an independent predictor of prognosis in both primary and metastatic disease, the study authors accessed clinicopathologic data for patients with melanoma included in the Surveillance, Epidemiology, and End Results (SEER) database, and a smaller New York University (NYU) cohort. In addition, for subsets of patients in the NYU cohort, response to particular systemic therapies in the metastatic setting were analyzed, and tumor specimens were assessed using a 140-gene nextgeneration sequencing panel.

A total of 118,508 patients (97,169 with SSM and 21,399 with NM) were identified in the SEER database from 1973 to 2012. The NYU cohort included 1111 and 510 cases of SSM and NM, respectively, during the period from 2002 to 2016.

In multivariate analyses controlling for thickness, ulceration, stage, as well as other variables, NM histologic subtype was an independent risk for death in both the SEER cohort (hazard ratio [HR]=1.55; 95% CI, 1.41 to 1.70; P <.001) and the NYU cohort (HR = 1.47; 95% CI, 1.05, 2.07; P=.03).

NM histologic subtype was also a statistically significant independent risk factor for death for patients with metastatic disease following treatment with BRAF-targeted therapy (HR = 3.33; 95% CI, 1.06-10.47; P =.04), but not with immunotherapy, represented mostly by ipilimumab monotherapy. ■ Read more at http://bit.ly/2JgB0o6.

For full news stories visit OncologyNurseAdvisor.com

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

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

Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/ PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS, clinical pharmacist specialist, Clear Lake Regional Medical Center, Webster, Texas.

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

Kerstin L. Lappen, RN, MS, ACNS, ACHPN, clinical nurse specialist, palliative care consult service, Abbott Northwestern Hospital, Allina Health System, Minneapolis, Minnesota.

K. Lynne Quinn, RN, MSN, CRNP, AOCNP, director of oncology, Bryn Mawr Hospital and Bryn Mawr Health Center, Bryn Mawr, Pennsylvania.

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

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

SHARING PERSONAL CONTACT INFORMATION WITH PATIENTS Some of my oncology nurse colleagues give patients their personal cell phone numbers. In my opinion, as harmless as it may seem, the practice sets up barriers for the rest of the team because some patients will not call back; rather, they only respond when they see my colleagues’ personal number as the caller.

I know we all have to make our own professional choices, but sometimes I feel like I’m the odd one for not giving my number when patients ask if they can text me. Am I behind the times? — Name withheld upon request In some work settings, nurses use work cell phones provided by their employer; however, the scene described here clarified that the nurses are using their personal cell phones.

This represents a big difference in expectations. When one is expected to use a work cell phone, expectations for terms, days, and hours of use should be clearly defined.

However, this situation sounds as though there are no employer-provided phones. but rather, colleagues are choosing to use their own personal phones. There may be potential ethical considerations, such as: professional boundaries (communication with only some patients outside of usual business hours), integrity (the kinds of interactions that are taking place), moral questions and/or expectations (feeling pressured to question your own professional behavior), and professional judgement (when behavior of someone on your team affects communication with the patient).

To answer your direct question, yes, times are changing; however, we still have professional and ethical responsibilities. We live in a world where people — not just patients — are used to having direct access to others at all times. Patients and/or families may have expectations that do not align with what’s possible in our work settings.

Boundaries are necessary to set proper expectations of the professional relationship.

Redirecting a patient or family member to the ways that they can reach you is acceptable.

— Eucharia Borden, MSW, LCSW, OSW-C

CAUTION REGARDING USE OF BURETROLS We currently use buretrols to administer chemotherapy on our pediatric unit.

I had heard that this equipment is vented and therefore causes aerisolization of hazardous drug. Is this true? — Name withheld on request Yes, there is a vent or air valve on the buretrol that allows for chemotherapy vapors to escape (aerosolize). This makes the device open and exposes staff, patients, and families to hazardous drug. Hence, the device would not be in compliance with <USP 800>.

These devices were often used to ensure timely drug delivery infusion rates. To minimize prolonged infusion times related to the IV pump or bag overfill, many facilities are weighing chemotherapy bags, including the percentage of overfill in the total volume, or allowing staff to increase infusion rates to ensure accurate completion times. — Leah A Scaramuzzo, MSN, RN-BC, AOCN

DO YOU HAVE A QUESTION FOR OUR CONSULTANTS? Send it to editor.ona@haymarketmedia.com.

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NAVIGATOR NOTES

© HERO IMAGES / GETTY IMAGES

S

mall-cell lung cancer (SCLC) has a strong tendency to metastasize to the brain, appearing in more than half of patients with a 2-year survival with SCLC. Because the bloodbrain barrier greatly reduces the efficacy of many chemotherapy treatments, other approaches for controlling metastasis of SCLC to the brain are often required.1 Prophylactic cranial irradiation (PCI) is a technique that has been used with the goal of preventing development of SCLC-related brain metastases.2 PCI is a radiation-based treatment that has been in use since before surveillance by magnetic resonance imaging (MRI) became standard. In theory, the risks brought on by radiation have been thought to be outweighed by the opportunity to control the spread of this aggressive cancer into the brain.3 However, whether PCI provides a survival benefit has not been clear, and the possible influence of physician bias around recommending PCI was explored in 2 recently published reports.4,5 One, a report by Tyler P. Robin, MD, PhD, of University of Colorado, and colleagues, presented the results of their study based on email surveys of self-reported physician attitudes toward PCI and on a patient decision aid that the researchers developed and made available to the physicians in their study for feedback.4 The second, a perspective piece

by Skyler B. Johnson, MD, PhD, and Roy H. Decker, MD, PhD, of Yale University School of Medicine, reviewed studies on PCI, including the report by Robin and colleagues.5

Influences on Decision to Use PCI for SCLC Brain Metastases Megan Garlapow, PhD

outcomes following the use of PCI,” stated Johnson and Decker.5 Individual studies in limited-stage SCLC have shown no benefit to overall survival (OS) using PCI, but a metaanalysis of studies involving limitedstage disease did show a profound OS benefit with PCI.5 In this analysis, 3-year survival was significantly higher with PCI (20.7%) vs without it (15.3%).6 Brain metastases also showed lower cumulative incidence at 3 years for patients who received PCI (33.3%) compared with those who did not (58.6%).6 CONFLICTING STUDY RESULTS

The decision to employ PCI for patients with limited-stage SCLC can be difficult, and “is best understood in the context of data surrounding disease outcomes and quality of life

Use of PCI in the context of extensivestage SCLC has also shown mixed results.3,5 Two landmark studies of survival in patients with extensive-stage disease showed conflicting results.

In 2007, the European Organization for Research and Treatment of Cancer (EORTC) found that OS was better for patients with extensive-stage SCLC who underwent PCI (median 6.7 months) compared with those who did not (median 5.4 months). Oneyear OS was 27.1% with PCI vs 13.3% without, and 1-year cumulative risk of brain metastases was 14.6% with PCI vs 40.4% with observation.7 These positive results in the EORTC trial with PCI in extensive-stage SCLC contrasted with those of a more recent multicenter trial in Japan, in which median OS was not significantly different with PCI (11.6 months) vs without PCI (13.7 months).8 Results from these studies may have differed based on study design differences. The EORTC trial utilized brain

Whether PCI provides a survival benefit has not been clear, and possible influence of physician bias was explored in 2 reports. www.OncologyNurseAdvisor.com • MARCH/APRIL 2019 • ONCOLOGY NURSE ADVISOR 9

NAVIGATOR NOTES scans less frequently (and only in the presence of neurologic symptoms) than did the Japanese study, which may have contributed to differences in application of salvage therapy between the 2 studies.5 Central nervous system staging may also have been determined differently between the studies, and therapy regimens may have differed in ways that contributed to disparate results.3 Beyond survival outcomes, a feature of PCI therapy is its risks to cognitive function. Different studies have shown varied outcomes for metrics of cognition, but pooled analysis indicated a more than three-fold worsening of cognitive function at both 6 and 12 months following PCI, with older patients showing more susceptibility.4,5 Quality of life also has been shown to suffer after PCI.5 THE PHYSICIAN PERSPECTIVE

In their recent study of physician bias around PCI, Robin and colleagues examined 295 responses (of 2007 that were sent to medical oncologists and 510 sent to radiation oncologists) from physicians located worldwide. Responses were to email surveys regarding personal and professional opinions about PCI for limited-stage SCLC. The physicians in this study were members of the International Association for the Study of Lung Cancer.4 Respondents overwhelmingly reported that they would recommend PCI to a 50-year-old patient (88% of respondents), and 50% would recommend PCI for a 70-year-old patient. Additionally, 79% of respondents indicated that they would choose PCI for themselves if they were the patients.4 This study revealed a strong correlation between physician preference toward receiving PCI for themselves and whether the physician would recommend PCI to a patient. Physicians who were willing to receive PCI were

27.6 times more likely to recommend it to a 50-year-old patient and 12.9 times more likely to recommend it to a 70-year-old, compared with physicians who would not personally accept PCI. These findings led the study authors to conclude that physician bias may be influential in recommending PCI to patients.4

The patient decision aid developed

by Robin and colleagues may form the basis for a useful strategy to help enable patients to make the choice about whether to undergo PCI.5 ■

THOUGHTS ON THE DECISION AID

1. Nakahara Y, Sasaki J, Fukui T, et al. The role of

Megan Garlapow is a medical writer based in Tempe, Arizona.

REFERENCES

The patient decision aid developed

by Robin and colleagues emphasized figures that displayed statistics for mortality, memory issues, and metastases to the brain in terms of numbers of persons per 100. It also provided textual descriptions of these statistics and other decision points that patients may wish to consider addressing with their physicians.4 The patient decision aid elicited overwhelmingly positive reactions from the physicians surveyed in the Robin study, with 79% agreeing that the aid would help patients make value-based choices. Furthermore, 84% considered

prophylactic cranial irradiation for patients with small-cell lung cancer. Jpn J Clin Oncol.

2018;48(1):26-30.

2. Witlox WJA, Ramaekers BLT, Zindler JD, et al.

The prevention of brain metastases in nonsmall cell lung cancer by prophylactic cranial irradiation. Front Oncol. 2018;8:241.

3. Rusthoven CG, Kavanagh BD. Prophylactic cranial irradiation (PCI) versus active MRI surveillance for small cell lung cancer: the case for equipoise. J Thorac Oncol.

2017;12(12):1746-1754.

4. Robin TP, Sannes TS, Spring Kong FM, et al. Physician bias in prophylactic cranial irradiation decision making-an opportunity for a patient decision aid. Clin Lung Cancer.

2018;19(6):476-483

The patient decision aid elicited positive reactions from the physicians surveyed.

5. Johnson SB, Decker RH. Prophylactic cranial irradiation versus surveillance: physician bias and patient-centered decision-making. Clin Lung Cancer. 2018;19(6):464-466.

6. Aupérin A, Arriagada R, Pignon JP, et al.

Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. Prophylactic Cranial Irradiation

the aid easy to understand. More than two-thirds considered the aid to be superior to their method of discussing choices regarding PCI.4 “In a patient-centered process, the decision as to whether to administer PCI or embark on a course of surveillance should certainly balance these well-described risks and benefits, but it is critical that this should reflect the patient’s, rather than the physician’s, values and priorities,” stated Johnson and Decker.5

14 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2019 • www.OncologyNurseAdvisor.com

Overview Collaborative Group. N Engl J Med. 1999;341:476-84.

7. Slotman B, Faivre-Finn C, Kramer G, et al; EORTC Radiation Oncology Group and Lung Cancer Group. Prophylactic cranial irradiation in extensive small-cell lung cancer. N Engl J Med. 2007;357(7):664-672.

8. Takahashi T, Yamanaka T, Seto T, et al.

Prophylactic cranial irradiation versus observation in patients with extensive-disease small-cell lung cancer: a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol. 2017;18(5):663-671.

FEATURE | Adverse-Event Management

Managing CINV and RINV: A Review of the Guidelines This review discusses where consensus and inconsistencies occur between the antiemesis guidelines from ASCO, MASCC/ESMO, and NCCN.

© BSIP / UIG / GEORGEPETERS / GETTY IMAGES / PHOTOILLUSTRATION: V CHANG

Lack of and inconsistencies across guidelines further challenge prevention and treatment of chemotherapy-induced and radiotherapy-induced nausea and vomiting.

BRYANT FURLOW

M

ost patients undergoing anticancer chemotherapy or radiation therapy will experience treatment-induced nausea and vomiting. But key gaps remain in our understanding of how best to prevent and treat this debilitating adverse effect, leading to inconsistencies among clinical antiemetic guidelines.

The available evidence for how best to prevent and manage nausea and vomiting during and following radiotherapy is particularly scant, precluding a comprehensive evidence-based consensus.

This article presents a review of the biologic pathways and treatment risk categories for chemotherapy-induced nausea and vomiting (CINV) and radiotherapy-induced nausea and vomiting (RINV), areas of consensus in the clinical guidelines from the American Society of Clinical Oncology (ASCO), the Multinational Association for Supportive Care in Cancer (MASCC) and European Society of Clinical Oncology (ESMO), and the National Comprehensive Cancer Network (NCCN) for preventing and managing CINV and RINV, and key evidence gaps for which additional research is urgently needed. Barriers to the effective implementation of guidelines are also described.

Chemotherapy- and radiotherapy-induced nausea and vomiting are common adverse events during cancer therapy, affecting most patients at some point during or following treatment.1-3 For example, 50% to 80% of patients undergoing radiotherapy for cancer will experience RINV.3 Surprisingly, given this ubiquity, the prevention

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FEATURE | Adverse-Event Management and management of these debilitating conditions has been relatively little studied in large, randomized, controlled prospective clinical trials.2,3 RINV, in particular, is underreported and has been under-researched.3 The resulting evidence gaps have contributed to differences in clinical guidelines’ recommendations for the prevention of CINV and RINV in certain patient populations and for the optimal management of breakthrough RINV.2,3 CAUSES AND TRIGGERS The biology of CINV and RINV are not completely understood. Nausea and vomiting are distinct, highly evolutionarily conserved biological mechanisms among vertebrates and are viewed as evolved adaptations for avoiding the harms caused by ingestion or inhalation of poisonous or infected substances.

Nausea involves autonomic nervous system pathways, whereas vomiting is a highly coordinated muscular activity controlled by the brain in response to stress, pain, smells, or tastes.1 The brain’s medulla oblongata harbors a chemoreceptor trigger zone of nerves receiving signals from the circulatory system that can trigger CINV in response to the presence of circulating chemotherapy agents.1 Sympathetic nerve signals indicative of noxious chemicals in the internal organs or acute inflammation also trigger vomiting.4 The neurotransmitters dopamine, serotonin (5-HT), neurokinin 1 (NK1), and substance P are involved in CINV- and RINV-triggering biological pathways and have each, therefore, been targeted in the development of antiemetic agents.4 CATEGORIZING EMETOGENICITY CINV or RINV episodes that occur within 24 hours of administration or exposure are considered acute, whereas delayed CINV and RINV occur more than 24 hours after treatment exposure.1 Psychosomatic anticipatory CINV and RINV also occur in a minority (up to 8%) of patients undergoing cancer treatment, particularly among those with previous exposure to emetogenic treatments.5 Different cancer treatment regimens carry different risks for acute or delayed nausea and vomiting. ASCO and the US National Cancer Institute (NCI) define highly emetogenic therapies as those that trigger nausea and vomiting in 90% or more of patients, whereas low-emetogenic and minimally emetogenic therapies trigger nausea and vomiting in 10% to 30% and less than 10% of patients, respectively.1-3,6 The severity of acute, late, or anticipatory nausea and vomiting is described using toxicity grades, as with other adverse effects of cancer therapy ( Table 1).

Generally, highly emetogenic chemotherapy includes high-dose cisplatin, carmustine, cyclophosphamide (at doses

Nausea involves autonomic nervous system pathways, whereas vomiting is a coordinated muscular activity controlled by the brain. exceeding 1500 g/m 2), dacarbazine, mechlorethamine, streptozocin, and anthracycline- and cyclophosphamidebased regimens.2 Moderately emetogenic chemotherapies include carboplatin, doxorubicin, irinotecan, oxaliplatin, and lower-dose cyclophosphamide regimens.2 Immunotherapies, targeted agents, docetaxel, pemetrexed, and eribulin are considered low-emetogenic treatments.2 (Some targeted and immunotherapeutic agents are considered minimally emetogenic. These include nivolumab, pembrolizumab, trastuzumab, and bevacizumab.2) Emetogenicity of radiotherapy varies primarily with the irradiated anatomy: total body irradiation is highly emetogenic, causing RINV in 90% of patients, whereas craniospinal and upper body and abdominal (upper abdominal) Table 1. NCI CTCAE: Nausea and Vomiting1,7 Adverse Event

Grade

Nausea

1

Loss of appetite without alteration in eating habits

2

Oral intake decreased without significant weight loss, dehydration, or malnutrition

3

• Inadequate oral caloric or fluid intake • Tube feeding, TPN, or hospitalization indicated

1

1-2 episodes (separated by 5 min) in 24h

2

3-5 episodes (separated by 5 min) in 24h

3

• ≥6 episodes (separated by 5 min) in 24h • Tube feeding, TPN, or hospitalization indicated

4

Life-threatening consequences Urgent intervention indicated

5

Death

Vomiting

Description

Key: CTCAE, Common Terminology Criteria for Adverse Events; NCI, National Cancer Institute; TPN, total parenteral nutrition.

16 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2019 • www.OncologyNurseAdvisor.com

radiotherapy are considered moderately emetogenic, causing RINV in 30% to 90% of patients.3 Central nervous system (CNS), head and neck, thoracic, and pelvic radiotherapy carry a low risk (less than 30%) of RINV, and limb and breast radiotherapy carry minimal (less than 10%) emetogenic risk.3 CONSENSUS AND INCONSISTENCIES ASCO, MASCC/ESMO, and NCCN have all produced clinical antiemetic guidelines for RINV and CINV.6,8,9 A recent review of the clinical guidelines for the prevention and treatment of CINV concluded that the MASCC/ESMO, ASCO, and NCCN guidelines offer “a relatively high degree of concordance” overall — with the ASCO and NCCN guidelines being most similar — and noted that some of the differences between these guidelines are due to an evolving evidence base between their publications (in 2016, 2017, and 2018, respectively).2 Chemotherapy-induced nausea and vomiting Recommendations for CINV prevention and treatment vary both between guidelines and by the emetogenic risks of the regimen. For prophylaxis among patients receiving highly emetogenic chemotherapy, ASCO recommends a 4-drug regimen of 5-HT3 receptor antagonist (RA), NK1 RA, olanzapine, and dexamethasone.2 For moderately emetogenic regimens, ASCO and MASCC/ ESMO both recommend 2-drug prophylactic regimens (5-HT3 RA plus dexamethasone) plus an NK1 RA for patients receiving carboplatin at doses of or exceeding an area under the curve (AUC) dose of 4 mg/mL per minute.2 NCCN recommendations offer 3 antiemetic dosing options; each includes dexamethasone and a 5-HT3 RA for acute cases.

One NCCN option for acute-onset CINV specifies palonosetron as the 5-HT3 RA, and another includes an NK1 RA.2,9 For low-emetogenic risk chemotherapy regimens, acute CINV is treated with either dexamethasone or a 5-HT3 RA under the ASCO guideline; or dexamethasone, metoclopramide, prochlorperazine, or a 5-HT3 RA under the NCCN guideline; or a 5-HT3 RA, dexamethasone, or dopamine RA under the MASCC/ESMO antiemetic guideline.2,6,8,9 None of the guidelines offer recommendations for minimally emetogenic chemotherapy regimens.2 MASCC/ESMO recommendations include aprepitant treatment for delayed CINV among patients taking carboplatin-based chemotherapy regimens; the ASCO guidelines offer no specific recommendations for these cases.2 Radiotherapy-induced nausea and vomiting A separate comparison of the ASCO, NCCN, and MASCC/ESMO clinical guidelines’ recommendations for the prevention and treatment of RINV came to a similar conclusion, noting differences between the guidelines in their recommendations for

preventing or treating RINV in patients undergoing low-risk and minimal-risk treatments, breakthrough RINV, and for patients undergoing concomitant chemoradiation therapy.3 For example, whereas the MASCC/ESMO and ASCO guidelines recommend employing CINV regimen antiemetic prophylaxis for patients undergoing chemoradiation, the NCCN guideline authors made no specific recommendations for antiemetic prophylaxis among patients undergoing concomitant chemoradiation.3,6,8,9 And whereas NCCN’s guideline recommends that patients who experience breakthrough RINV be treated similarly to patients with breakthrough CINV, with a different class of antiemetic therapy, or with the 5-HT3 RA ondansetron or granisetron; the ASCO and MASCC/ESMO guidelines do not address breakthrough RINV.3,6,8,9 NCCN does not make recommendations for treating low- or minimal-emetogenic-risk radiotherapy, whereas the other guidelines recommend 5-HT3 RA, dopamine receptor antagonists (DRAs), or dexamethasone for prophylaxis and rescue antiemesis for low-risk radiotherapy and 5-HT3 RA, DRA, or dexamethasone for rescue.3,6,8,9 For patients at high risk of RINV, all 3 guidelines recommend prophylaxis with a 5-HT3 RA and dexamethasone or optional dexamethasone.3,6,8,9 For patients at moderate risk of RINV, the 3 guidelines recommend varying regimens of prophylactic 5-HT3 RA and dexamethasone.3,6,8,9

Recommendations for CINV prevention and treatment vary both between guidelines and by emetogenic risks of the regimen.

More research is needed for optimal anti-RINV regimens and antiemetic dosing schedules, particularly for patients undergoing low- and minimal-emetogenic risk radiotherapy and for how best to treat breakthrough RINV.3 BARRIERS TO IMPLEMENTATION Perhaps in part because of the inconsistencies between the ASCO, NCCN, and MASCC/ESMO clinical guidelines and resulting confusion about which guidelines should be followed, antiemetic recommendations have not been consistently implemented in oncology centers, despite evidence that implementation of individual guidelines’ recommendations can reduce the severity of acute treatment-associated nausea and vomiting and can reduce cancer care costs.3 Continues on page 18

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FEATURE | Adverse-Event Management Guideline nonadherence also stems from institutional policies and traditions.3 However, as with the empirical evidence base for CINV and RINV prevention and management, the evidence for implementation of antiemetic guidelines is represented in only a handful of published studies and more research on adherence is needed.3 Successful clinical implementation of

about-cancer/treatment/side-effects/nausea/nausea-hp-pdq. Accessed March 12, 2019.

2. Razvi Y, Chan S, McFarlane T, et al. ASCO, NCCN, MASCC/ESMO: a comparison of antiemetic guidelines for the treatment of chemotherapyinduced nausea and vomiting in adult patients. Support Care Cancer.

2019;27(1):87-95.

3. McKenzie E, Zaki P, Raman S, et al. Radiation-induced nausea and vomiting: a comparison between MASCC/ESMO, ASCO and NCCN antiemetic

The evidence for implementation of antiemetic guidelines is represented in only a handful of published studies and more research is needed.

guidelines. Support Care Cancer. 2019;27(3):783-791.

4. Rao KV, Faso A. Chemotherapy-induced nausea and vomiting: optimizing prevention and management. Am Health Drug Benefits.

2012;5(4):232-240.

5. Molassiotis A, Lee PH, Burke TA, et al. Anticipatory nausea, risk factors, and its impact on chemotherapy-induced nausea and vomiting: results from the Pan European Emesis Registry Study. J Pain Sympt Manag.

guideline recommendations will likely require interdisciplinary coordination, clinician education, clinical workflow reminders, clinical practice audits, and pharmacist interventions to promote antiemetic prescribing, according to one recent review.3 Guidelines are “only effective if they are put into practice,” noted a review of antiemetic recommendations for RINV.3 “There is a necessity for the implementation of systems that promote guideline adherence and aid healthcare providers to prescribe the optimal RINV antiemetic regimens in order to optimize quality of life for patients.” ■

2016;51(6):987-993.

6. Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol.

2017;35(28):3240-3261.

7. US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. https://www.eortc.be/services/doc/ ctc/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf. Accessed March 12, 2019.

8. Roila F, Molassiotis A, Herrstedt J, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer

REFERENCES

patients. Ann Oncol. 2016;27(suppl 5):v119-v133.

1. Treatment-Related Nausea and Vomiting (PDQ®) — Health Professional Version. National Cancer Institute website. https://www.cancer.gov/

9. Ettinger DS, Berger MJ, Aston J, et al. NCCN Guidelines Insights: Antiemesis, Version 2.2017. J Natl Compr Canc Netw. 2017;15(7):883-893.

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FEATURE | Cancer in the Elderly

Adjusting Treatments for the Nonfrail Elderly With Cancer This clinic treats older patients based on an assessment of their biological age, which is a better measure of their ability to tolerate treatment.

© WARREN DIGGLES PHOTOGRAPHY / GETTY IMAGES

A younger biological age may indicate a patient is better able to tolerate aggressive, intent-to-cure cancer therapy.

BETTE WEINSTEIN KAPLAN

O

ncologist Ashley Rosko, MD, has a unique perspective on patient age: Biological age is more important than chronological age. Dr Rosko is founder and director of the Cancer and Aging Resiliency (CARE) Clinic, a multidisciplinary clinic designed to address the needs of older adults with cancer. The clinic is located in The James Cancer Hospital at The Ohio State University, where Dr Rosko is associate professor in the Department of Internal Medicine.1 Dr Rosko conducts research using the biological age of older patients, rather than their chronological age, to better understand their ability to tolerate aggressive cancer therapies.

She recognizes that older adults with cancer may be undertreated or never treated. Her goal is to systematically improve cancer care for older adults in terms of complications, hospitalizations, and overall survival.

AGE, HEALTH, AND CANCER TREATMENT

No two people age the same way. This is especially obvious in terms of how their health changes. Older people with cancer may otherwise be fit and exercise on a regular basis, whereas others are frail and unable to tolerate chemotherapy for any number of reasons. Many factors can contribute to frailty, including comorbidities, difficulties at home, or caregiver issues.

Dr Rosko says her group has no age-related cutoff or limitations of any kind regarding bone marrow transplant for patients with multiple www.OncologyNurseAdvisor.com • MARCH/APRIL 2019 • ONCOLOGY NURSE ADVISOR 25

PB ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2019 • www.OncologyNurseAdvisor.com

FEATURE | Cancer in the Elderly myeloma. Patients are asked to come into the clinic so they can be evaluated for any occult issues. If someone arrives in a wheelchair or directly from a nursing home, staff can easily determine that that patient is frail; ambulatory patients with good functionality are obviously fit. However, many patients are vulnerable because they fall in between frail and fit.

Oncologists should be certain they are screening appropriately, so that if they recommend an intensive treatment, such as a bone marrow transplant, the treatment really makes sense for that patient, Dr Rosko explained to Oncology Nurse Advisor.

Assessments of older patients should consider that not all 70-year-old patients would be in the same physical condition.

With the CARE Clinic, the Ohio group has evolved a way to figure out older patients’ biological age. They measured all the variables associated with bone marrow transplant and put together a plan to help facilitate bone marrow transplant decisions. If there is an alternative they can talk about it. If there is no alternative, they discuss ways to control the adverse events.

ANCILLARY CARE IN A CENTRAL LOCATION When Dr Rosko opened the Cancer and Aging Clinic in 2016, it was specifically for patients with blood cancers. A focus was on multiple myeloma, an uncommon blood cancer of older adults known for its chronicity in which patients can have many good years. The clinic combines innovative research into aging with appropriate care for older patients.

It was expanded in 2018 to cover solid tumors, becoming the multidisciplinary Cancer and Aging Resiliency Clinic.

Its focus is on how cancer treatment affects patients’ quality of life in relation to geriatric syndromes. Some patients are affected by their cancer in many ways, whereas some experience more moderate effects. At the clinic, patients discuss insomnia, falls, neuropathy, and other issues related to how chemotherapy has affected them.

The 7-person clinic team evaluates each patient for treatment eligibility. Dr Rosko screens patients for anxiety and depression; a nurse specialist performs a cognitive assessment; and a physical therapist conducts a number of functional evaluations including Timed Up and Go, a gait assessment, and a multilevel balance evaluation. Patients see a nutritionist who can evaluate their appetites and discuss the need for an appetite stimulant.

A new hearing loss may go on the back burner when a patient finds out he or she has cancer. But because hearing deficits are common in the elderly, the clinic has a sound booth and patients can undergo an audiometry test. They can then take the results anywhere to get hearing aids.

A nurse case manager discusses the patient’s home: Is the patient a caregiver for someone else? How is the patient functioning? What are the financial limitations and health costs?

A clinic pharmacist reviews all the patient’s medications and calls the patient’s pharmacy if there are issues. The clinic pharmacist also creates a plan for identifying potential drug/ drug interactions or medications that are contraindicated with the planned chemotherapy. Patients are often seeing

“We can potentially save patients the trouble of having to go to 6 different appointments. It’s nice to do that,” Dr Rosko noted. multiple oncologists. They may be taking medications they no longer need, that are duplicates of another prescription, or that interact with other drugs the patient is taking.

HOW THE CLINIC WORKS A clinic visit lasts approximately 2 hours. Each specialist rotates for 20 minutes, ascertaining if there are certain deficits, then all the specialists meet to discuss their findings. For example, if a patient needs medication for neuropathy but cannot afford it, the case manager will try to arrange for the patient to obtain the medicine at an affordable price. Staff may involve the integrative medicine clinic or the survivorship clinic to offer massage therapy and reflexology. Although all of these services are available in most cancer centers, the CARE Clinic provides access to them in a single visit at a central location, so patients, family members, or caregivers do not have to visit multiple places. “It’s kind of one-stop shopping. We can potentially save patients the trouble of having to go to 6 different appointments. It’s nice to do that,” Dr Rosko noted.

Patients attend the CARE Clinic one time, then go back to their regular clinicians. Staying in touch with all healthcare providers is important for patients and families, especially if the patient is frail. Most people want to know that everything that could have been addressed, actually was. Dr Rosko knows that even with her innovations in care uncovering specific biomarkers to determine biologic age is challenging. However, she is confident this knowledge will lead to better quality of life for patients and, eventually, improve survival. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

REFERENCE 1. Rosko AE, Huang Y, Benson DM, et al. Use of a comprehensive frailty assessment to predict morbidity in patients with multiple myeloma undergoing transplant [published online July 5, 2018]. J Geriatr Oncol. doi: 10.1016/j.jgo.2018.05.015

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© P. MARAZZI / SCIENCE SOURCE

RADIATION & YOUR PATIENT

Joint Guideline Issued for Abbreviated RT for Prostate Cancer Bryant Furlow The American Society for Radiation Oncology (ASTRO), American Society of Clinical Oncology (ASCO), and American Urological Association (AUA) published an evidence-based clinical guideline on hypofractionated radiotherapy for early-stage prostate cancer, recommending it as an alternative to conventional radiation regimens when patients opt for treatment instead of active surveillance or surgery.1

C

onclusive evidence from several large, well-designed randomized trials now confirms that dose escalation can almost universally benefit

men with early-stage prostate cancer who choose to manage their disease with external radiation,” said Howard Sandler, MD, FASTRO, FASCO, chair of radiation oncology at Cedars-Sinai Medical Center, who co-chaired the 16-member expert guideline panel, in a press release.2 “Significant advances in treatment planning and delivery have enabled oncologists to deliver more powerful, life-saving doses of radiation in fewer visits and without compromising quality of life.”

The panelists unanimously agreed that image-guided radiation therapy (IGRT) should be used with hypofractionated external beam radiotherapy (EBRT). The guideline did not address radiotherapy for locally advanced or metastatic prostate cancer, adjuvant radiotherapy, or re-irradiation.

External beam radiotherapy is the standard definitive treatment, offering outcomes equivalent to radical surgical prostatectomy for early-stage prostate cancer.1,2 Hypofractionated radiotherapy should be offered to patients who forego active surveillance and wish to undergo EBRT rather than radical surgery or brachytherapy, the guideline authors recommended.1 “Results so far show comparable early cancer control to conventional fractionation, while maintaining an acceptable side effect profile,” Daniel Barocas, MD, associate professor of urology at Vanderbilt University Medical Center, stated in a press release.2 “This has benefits to the patient in terms of reducing the treatment burden and cost, and may increase the acceptability of external beam radiation therapy.”

Hypofractionation allows largerdose radiation fractions to be delivered in fewer sessions, with the total dose completed in 5 weeks or less vs up to 9 weeks with conventional

radiation dose-fractionation schedules.2 Ultrahypofractionation (stereotactic body radiation therapy [SBRT] or stereotactic ablative radiotherapy [SABR]) can involve 5 radiation sessions.1,2 Moderately hypofractionated radiotherapy involves radiation doses of 240-340 cGy per fraction and ultrahypofractionated involves at least 500 cGy.1 Moderate hypofractionation should be offered to patients with localized prostate cancer who are candidates for EBRT, they wrote — regardless of patient age, comorbidities, or urinary function.1 But clinicians should discuss with patients the limited high-quality clinical trial evidence base for prostate cancer control beyond 5 years, particularly for moderate hypofractionation.

Based on high-quality evidence, moderate hypofractionation (240-340 cGy per fraction) should be recommended to patients in all risk groups, the guideline states.1 Based on a moderate-quality evidence base, the guideline authors conditionally recommended hypofractionated regimens of 6000 cGy delivered in 20 fractions of 300 cGy and 7000 cGy delivered in 28 fractions of 250 cGy for men with localized prostate cancer, explaining that a single optimal regimen cannot yet be identified with the limited available data from clinical trials. These 2 regimens are supported by the available evidence.

A single optimal regimen cannot yet be determined because few fractionated regimens have been evaluated in head to head clinical trials, the authors noted.1 The guideline recommendations for ultrahypofractionation varied by risk group. The ASTRO/ASCO/AUA guideline conditionally recommended against ultrahypofractionated radiation therapy for patients with high-risk prostate cancer. Based on a moderate-quality evidence base, the guideline states

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RADIATION & YOUR PATIENT

Hypofractionation allows large-dose radiation fractions in fewer sessions. that ultrahypofractionated radiation therapy may be offered to patients with low- or intermediate-risk prostate cancer but “strongly encourages treatment of intermediate-risk patients on a clinical trial or multi-institutional registry.”1 For any hypofractionated EBRT, the task force strongly recommended the use of image-guided radiation therapy and recommended against the use of

radiation-unmodulated 3-dimensional conformal radiotherapy techniques.1 The panel suggested ultrahypofractionation schedules of 3500 cGy delivered in 5 fractions of 700 cGy or 3625 cGy in 5 fractions of 725 cGy.1,2 Consecutive (ie, day-after-day) fractions should not be planned, however.

The panelists reviewed 61 studies published between December 2001 and March 2017 that included 4 large randomized clinical trials.1,2 ■

Hypofractionated radiation therapy for localized prostate cancer: an ASTRO, ASCO, and AUA Evidence-Based Guideline. J Clin Oncol.

2018;36(34):3411-3430.

2. New ASTRO/ASCO/AUA guideline for early-stage prostate cancer supports use of shortened courses of radiation therapy [news release]. Arlington, VA; Alexandria, VA; Chicago, IL: American Society for Radiation Oncology (ASTRO), American Society of Clinical Oncology (ASCO), American Urological Association; October 11, 2018. https://www.astro.

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

org/News-and-Publications/News-andMedia-Center/News-Releases/2018/ New-ASTRO-ASCO-AUA-guideline-for-

REFERENCES

early-stage-prost. Accessed February

1. Morgan SC, Hoffman K, Loblaw DA, et al.

15, 2019.

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COMMUNICATION CHALLENGES

Guide Dogs and White Canes

© A-DIGIT / GETTY IMAGES

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

Who are our guide dogs as nurses?

Who are the guide dogs for patients?

How do we become the guides when we meet resistance?

H

alloween night my husband and I were taking turns answering the door to trick or treaters. In between the dinging of the doorbell, we had our noses in our laptops checking on emails and social media. My husband started laughing so hard he began to cough, and tears came to his eyes.

“What?” I asked.

He turned his monitor toward me. An airline pilot had gotten into the spirit of Halloween. Posted on social media was a picture of him walking through an airport terminal. He wore his full uniform and pilot cap, nothing unusual there, but he also wore sunglasses and walked with a white cane extended in front of him. So funny.

A day or two later I realized the humorous image actually could be a metaphor for some of our patients. They approach their illness with the air of expertise (“I’ve read everything out there on the internet”), walking through the cancer journey with as much authority

and confidence as if they were wearing a uniform and cap. They seem to carry the tools they need to navigate their journey, yet on a fundamental level lack an understanding of the complexity of the situation.

How long does it take until some patients realize they cannot see?

There is a Netflix movie called Bird Box. In the postapocalyptic setting of this movie, anyone who looks at the alien entity will be destroyed. To survive they must cover their eyes. All of the characters exist in this new world with their eyes covered. When we talk about patients or families in denial or having difficulty coping, I think of that crazy photo of the pilot on Halloween or the movie trailer with characters in Bird Box wearing bandanas covering their eyes.

In both examples it is easy to see the irrationality of the coping strategy, yet patients may not. And sometimes we may not either.

These may seem like silly examples, but they point out a subtle truth. We say a patient or family is in denial or that “they just don’t get it.” We can’t understand why when we know they have been told what is going on.

The pilot walking through the airport or the actors wearing bandanas over their eyes may seem absurd, but in both instances they are reacting to the world they believe they live in in that moment. There is a myth, especially here in the United States: the “you can do it, nothing is impossible” myth. Where folks think they can cheerlead themselves or their loved ones into overcoming the impossible.

With just the right cane or the right bandana they can weather the storm. For the silly pilot walking through the airport with a white cane or the characters in the movie, they place their survival on believing an untruth.

www.OncologyNurseAdvisor.com • MARCH/APRIL 2019 • ONCOLOGY NURSE ADVISOR 29

COMMUNICATION CHALLENGES

To guide our patients, we have to be patient.

We have to repeat ourselves. We have to ask questions.

Sometimes we have to say nothing.

What happens if I think they do not need the cane, if I point out what is obvious but which they are not ready to consider? What if I pull their cane away?

Even more importantly, what are the white canes and bandanas that I have in my practice?

CASE One communication challenge many of us will encounter is how to have a conversation about unrealistic expectations. What do I say when a patient who is clearly in the final stages of their disease, tells me they think they might have another 1 to 2 years, when I know that the reality is 1 to 2 more months?

What do we do when we encounter patients who have their eyes covered and yet believe they can see, that they know what is going on but believe that by sheer will they can survive? They don’t see the two sidedness of the relationship they have been forced into with their disease. Surely someone must show them the way.

I did just that recently. I did it because I thought I needed to, and because I thought I knew better. It is hard not to transfer what I know professionally to a family situation.

All eyes were on me when I went with my mother to visit her sister Cheryl whose pancreatic cancer had been diagnosed 3 months earlier. My one cousin was micro-managing her mother’s diet, convinced that she could alter the course of disease by encouraging her to only eat vegan food, no sugar, no processed foods. I saw immediately that Cheryl had lost weight. She told me the diet she was following was not appealing. In my zeal to be helpful, I quickly shot down the whole diet strategy and told my cousin that losing weight was far more dangerous than the additives and processed foods she restricted her mother.

I thought I was gentle in my approach, first praising Terry for her determination to help, not dismissing it full scale but suggesting adjustments. It didn’t fit Terry’s idea though.

She was trying to save her mother, and I came along and put my big fat foot right in

the middle of everything. Essentially, I hit her over the head with the truth and a reality she wasn’t yet ready to accept. With the best of intentions, I wrenched her white cane away and left her without a way to navigate.

DISCUSSION The title of this essay is “Guide Dogs and White Canes” for a reason. Who are our guide dogs as nurses? Who are the guide dogs for patients? How do we become the guides when we meet resistance?

There is an old medical construct called tincture of time. I needed to give my cousin a tincture of time, the chance to adjust even when I knew the clock was ticking. I knew that, but she did not; and by rushing on ahead instead of encouraging a forward motion, she put on the brakes. I needed to wait for her to catch up. I couldn’t expect her to take giant steps to catch up. I needed to slow down.

I knew the way, but she could not keep up and I could not hurry her along.

So, what do we do? To guide our patients and family members, we have to be patient.

We have to repeat ourselves. We have to ask questions. Sometimes we have to say nothing, which is the hardest of all. I heard a podcast recently that spoke of the unthought known — a phrase coined by Christopher Bollas in the 1980s — in other words, something that is known on some level but unable to be thought about. It is more nuanced than denial and less deliberate than manipulation.

It has more to do with allowing time and creating an environment for that unthought known to emerge. We may, as practitioners, need to fashion a setting that is conducive to that. We may need to wait even when we feel impatient. Inadvertently, I forced the information on my cousin, and in spite of being well intentioned, it was too much too soon for her. A guide dog guides and protects, nudges and directs, slows or stops when necessary. Something we can apply in our practice. ■ Ann Brady is a symptom management care coordinator at a cancer center in Pasadena, California.

30 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2019 • www.OncologyNurseAdvisor.com

ISSUES IN CANCER SURVIVORSHIP © SILVIAJANSEN / GETTY IMAGES

Helping Patients Face the Challenge of Eating Healthy During Cancer Treatment Bette Weinstein Kaplan

T

he National Cancer Institute reported that the United States was home to an estimated 15.5 million cancer survivors in 2016, and an estimated 1,735,350 new cases of cancer were diagnosed in 2018.1 The number of people surviving cancer is expected to increase to 20.3 million by 2026.1 All of these patients and survivors need optimal nutrition; however, they either cannot or do not want to eat the way they used to. Whether this is the result of their disease or its treatment, cancer patients and those who have come through their treatment often have trouble eating, spawning cookbooks and expert advice.

Here are 2 examples.

ACS UPDATES ITS CLASSIC COOKBOOK

The American Cancer Society (ACS) published a second edition of its healthy eating guide, What to Eat During Cancer Treatment.2 The 288-page volume features more than 130 easy-to-prepare recipes along with practical advice.

Recipes focus on cancer patients’ specific needs. These foods can help patients cope with treatment-related side effects and other eating challenges while undergoing treatment and afterwards. Although specialized for cancer survivors, the recipes create meals that appeal to those with many different taste preferences and in many phases of health. They can also be surprisingly

gourmet, incorporating foodie-inspired trends such as acai, kale, quinoa, and whole-wheat pasta.2 The recipes are organized into 7 groups by common eating-related side effects of cancer treatment: nausea, diarrhea, constipation, trouble swallowing, sore mouth or throat, unintentional weight loss, and taste changes. Each group of recipes begins with information on the respective side effect and how to manage it, incorporating clinical experience and evidence-based research. Color-coded letter symbols are used to identify each side effect, making the book a versatile resource for eating while dealing with the different types of cancer and treatment phases.

Although it is a cookbook, What to Eat During Cancer Treatment includes extensive advice for caregivers, answers to common questions, important food

“There is a healing quality to having food you can enjoy.”

— Jeanne Besser safety precautions, and guidance for eating and living well after treatment This second edition is written by several experts: Jeanne Besser, an awardwinning cookbook author; oncology

dietitian Barbara Grant, MS, RDN, CSO, a board-certified specialist in oncology nutrition; and other experts in nutrition and cancer care from the American Cancer Society. “There is a healing quality to having food you can enjoy even if you’re undergoing difficulties that can come with cancer treatment. You can take comfort from getting the nutrition you need and knowing you’re doing good things for your body by eating healthy food that can help you feel better,” Ms Besser said.

CHOPPED CHAMPION COOKS UP HEALTHY MEALS FOR CANCER PATIENTS

Chef Pnina Peled knows cancer nutrition well. She was executive chef at Memorial Sloan Kettering Cancer Center (when Oncology Nurse Advisor last spoke with her), and is now senior executive chef at New York-Presbyterian/ Columbia University Medical Center, both in New York City. Chef Peled is responsible for all food served or sold in New York-Presbyterian hospitals, whether it is in a patient’s room, the cafeteria, or the gift shop. She has great expertise in creating attractive and nutritional food. She is aware that active treatment alters a patient’s appetite and palate, and that the goal after treatment is to strengthen the body again.

Chef Peled offers this advice to cancer survivors: “When you’re in treatment,

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ISSUES IN CANCER SURVIVORSHIP concentrate on what you can eat and what tastes good because treatment side effects alter taste. Treatment also affects what you’re able to tolerate. Eating a balanced diet is the most important thing you can do for yourself after treatment. Fresh fruits and vegetables, lean meats, healthy carbohydrates like beans and grains, those are the foods to go for. One thing I would say — and I always say this — is to keep away from processed foods. Try to stick with whole foods. Real foods. This is the way I usually put it, ‘If it comes in a box, can, jar, or a container of any kind, it’s processed. Don’t buy it. If you read the ingredients and you can’t understand the first 5 words, don’t buy it.’ It’s better to eat simple, which means simple whole, real foods than to eat processed foods that seem appealing because of the way they’re marketed.”

Oncology Nurse Advisor asked Chef Peled for her advice for the woman who is exhausted from having gone through the ordeal of breast cancer

treatment. The last thing she wants to do is shop and then cook. How does she get through that?

Cook in advance “She can cook in advance, which I recommend most often. For example, prepare a batch of stew and portion it out, then freeze a few portions for those days when she doesn’t feel like cooking. Also when cooking for herself, I recommend cooking more than the number of portions she’s going to eat today or tomorrow. I suggest she cook 4 or 5 portions, so she can reserve some and freeze it for those less-than-ideal days,” advised Chef Peled.

The Food Network Chopped champion said there are other easily prepared meal items that cancer survivors should consider. One can easily make scrambled eggs, add cheese to them if desired (she likes Gruyère or Swiss), and serve with fresh fruit. “The way I make scrambled eggs is simple. I like the yolk a bit soft so I melt unsalted

If you cook 1 day a week, you can adequately portion your meals. butter in a nonstick pan, crack 2 eggs, and scramble them in the frying pan. I only add a bit of kosher salt and make sure the eggs are still soft and not overcooked,” explained Chef Peled. “Or you can throw some potatoes in the oven and have a big baked potato with all sorts of yummy toppings on it.”

Many meals are quick and easy to make, and only require a little thought beforehand. Chef Peled suggested buying a vacuum-sealing machine; they are so useful and their cost has come down.

“For example, cook a roast chicken, then portion it out, vacuum seal it, and freeze. When you’re ready to eat it, you can cook the portion right in the sealed bag. Just place it in simmering water

Chef Pnina Peled’s Mediterranean Baked Eggs Serves 4

Ingredients:

1 tablespoon extra-virgin olive oil ½ white or yellow onion, sliced thin 1 teaspoon garlic, minced (jarred minced garlic in oil is okay) ½ yellow or green bell pepper, sliced thin 16 oz tomato sauce (quality store-bought brand is okay)

¼ teaspoon salt pinch of black pepper ¼ teaspoon smoked paprika 8 eggs

Directions: • In a large skillet, heat the olive oil until shimmering.

• Add the onion and cook on medium-low heat until golden, stirring regularly to avoid burning.

• Add the garlic and mix to combine. Cook for approximately 3 minutes.

• Add the pepper and mix to combine, cooking for another 3 minutes.

• Mix in the tomato sauce; add salt, black pepper, and paprika and allow to cook until the sauce begins to bubble.

• Lower to heat to simmer and crack the eggs directly over the sauce, making sure to keep some distance between each egg.

• Cover and allow to simmer until the white portion of the egg is cooked through and the yolk is still soft.

• Remove from heat and serve with your favorite bread.

32 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2019 • www.OncologyNurseAdvisor.com

until it reaches 165 degrees. This way the food will stay moist. Like sous vide.

Cooking in batches and freezing is, in my opinion, the best way to make sure you have healthful food available all the time,” she said.

Chef Pnina Peled’s Vegetable Tagine Serves 8

Ingredients: ¼ cup extra virgin olive oil, plus more for later 2 yellow onions, peeled and chopped 10 garlic cloves, peeled and chopped 2 large carrots, peeled and chopped 2 large red potatoes, peeled and cubed 1 large sweet potato, peeled and cubed

Plan menus Chef Peled suggests devel-

oping a menu for the week. “If you cook for several hours 1 day a week, you can actually adequately portion your meals. That’s the way to maintain proper portions and eat a balanced diet.

You’re not just scooping heaps of food on your plate. Research has shown that people will eat with their eyes. So if you portion your meals like that and freeze the portions, you’re making sure that you get the ideal quantity of calories and nutrients.” ■

1 1 ½ 2 ½ 1 2 1 ½

Salt teaspoon ground coriander teaspoon ground cinnamon teaspoon ground turmeric cups canned whole peeled tomatoes cup chopped dried apricots quart low-sodium vegetable broth cups cooked chickpeas lemon, juice bunch fresh parsley, chopped

Directions: • In a large pot or Dutch oven, heat olive oil on medium heat until just shimmering. Add onions; raise the heat to medium-high and sauté until translucent.

• Add garlic, chopped veggies, salt, and spices. Toss well to combine.

• Cook for approximately 8 minutes on medium-high heat, mixing regularly with a wooden spoon.

• Add tomatoes, apricots, and broth.

• Cook on medium-high for 10 minutes more.

• Reduce the heat, cover, and simmer for another 30 minutes or until veggies are tender.

• Stir in chickpeas and cook another 10 minutes on low heat.

• Stir in lemon juice and fresh parsley.

• Taste and adjust seasoning. Serve with rice or couscous.

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

REFERENCES 1. Cancer statistics. National Cancer Institute website. https://www.cancer.gov/aboutcancer/understanding/statistics. Updated April 27, 2018. Accessed January 17, 2019.

2. Besser J, Grant B; the American Cancer Society. What to Eat During Cancer Treatment.

2nd ed. Atlanta, GA: American Cancer Society; 2018.

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FROM Supporting Changes in Need After a Cancer Diagnosis A.J. Cincotta-Eichenfield, LMSW

assistance at each stage. People living with cancer may feel alienated from previous support systems whose members do not understand the cancer experience. Feelings of isolation can arise if friends and family shy away from conversations and interactions due to the stigma of cancer and fear

of adverse outcomes.3 This isolation can also be due to misunderstandings about or fear of cancer, discomfort in starting conversations and maintaining communication, or the intense emotional nature of lending certain kinds of support. People living with cancer may have difficulty finding others who “get it” and fit into needed support roles. Friends and family, though often well-intentioned, may say things that reflect that they don’t understand the reality of the situation. They may also perceive themselves as protecting the person with cancer by not engaging in difficult conversations, all of which can magnify the physical and emotional losses for those living with cancer.

MATCH SUPPORT TO NEEDS The need for social support after a diagnosis should be individualized and can manifest differently depending on a variety of illness factors. Socioeconomic dimensions, cultural contexts, and a person’s social and emotional strengths should be taken into account. Having this knowledge allows healthcare professionals to trace the different ways that people seek support and assess what resources may be most useful to them.

Social support can take many forms for people with cancer. A few examples are check-in call, an online fundraiser, a trip to treatment, delivery of groceries or meals, or a hospital visit.

Social support, when present and able to adapt to the challenges of cancer, can provide constancy, engagement, positivity, and hope. Though varied in nature, having a community of support can offset some of the secondary

A support network can be instrumental in enhancing quality of life for patients by influencing mood, sense of self, and identity.

34 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2019 • www.OncologyNurseAdvisor.com

© H ERO IMAGES / GETTY IMAGES

A

cancer diagnosis can signal a prescriptive shift from that which is known and normal to a new reality. An unfamiliar network of doctors and healthcare professionals and an unforgiving schedule of appointments, scans, and treatments becomes a new normal. Cancer can feel irreducible and all-encompassing, requiring the full attention, support, and mobilization of support networks surrounding the person with the cancer diagnosis. Social support can, and often does, emerge as a means of coping with the everyday challenges of a cancer diagnosis; mediating against the logistical, emotional, and physical burdens associated with cancer.

The need for support varies with the physical impact of an illness (ie, symptoms, treatment, and adverse effects) and support offered should take into account the patient’s illness context, involve open communication, and work to provide instrumental or emotional support that appropriately matches the patient’s needs.1 As patients navigate through the cancer experience, the restructuring of relationships can have implications on coping and self-management during diagnosis and treatment, which may consecutively change the ways that patients access and participate in health-promoting activities and contextualize and integrate cancer into their lives and identities.2 Relationships with friends and family can be strengthened, or alternately, prove to be less helpful than anticipated.

Existing networks may not always be prepared to offer emotional or logistical

stress of planning and logistics, allowing patients to focus their energy on treatment and coping. Having social support after a cancer diagnosis is linked to decreased experience of psychological symptoms and higher measures of well-being, while also functioning as a protective factor against adverse health outcomes and mortality.4 A support network can also be instrumental in enhancing the quality of life for people living with cancer, by influencing mood, sense of self, and identity.4 Oncology nurses, social workers, and other healthcare professionals can work with patients and caregivers to highlight the strengths of existing social connections, empower patients to develop adaptive coping mechanisms, and search for additional support and resources outside of their networks or areas of expertise. Oncology nurses, in particular, are well-positioned to do so as they can provide supportstrengthening strategies in ways that are realistic and informed by individual medical needs and the social context of the person with cancer.2 Professionals experienced in the needs of people impacted by cancer can assist patients and caregivers in defining and refining what their needs are, which can create clarity for those around them who may be interested in helping. Peer

support organizations, such as Imerman Angels, and organizations that provide a combination of professional and peerbased programs, such as CancerCare and Cancer Support Community/Gilda’s Club, may prove useful in creating meaningful connections in the lives of patients and caregivers after a diagnosis.

Professionally led support groups — whether in-person, online, or via telephone — can help people living with cancer find a space where their thoughts and feelings surrounding a diagnosis are heard and validated.3 Online tools such as My Cancer Circle, can help caregivers more efficiently organize

from professionals with a specific background in oncology can mediate stress by providing new pathways to experiential knowledge. Most importantly, healthcare professionals who specialize in oncology can help people living with cancer respond to and cope with a diagnosis by creating connections in ways that existing systems of support may not be equipped to provide. ■ A.J. Cincotta-Eichenfield is an oncology social worker with CancerCare.

REFERENCES 1. Merluzzi TV, Philip EJ, Yang M, Heitzmann CA. Matching of received social support

People living with cancer don’t have to go far to find others with their diagnosis.

with need for support in adjusting to cancer and cancer survivorship. Psychooncology.

2016;25(6):684-690.

2. Henshall CL, Greenfield SM, Gale NK. Typologies for restructuring relationships in cancer survivorship. Cancer Nurs. 2018;41(6):E32-E40.

3. Clarke PG, Bolte S. Sense making in living with cancer as a chronic illness. In Christ

their communities of support, formally outlining roles and responsibilities for friends, and creating a space for open communication within a network.

Communities of support have become evermore specific in the digital age and people living with cancer don’t have to go far to find others with their diagnosis. Peer support and support

G, Messner C, Behar L, eds. Handbook of Oncology Social Work: Psychosocial Care for People with Cancer. New York, NY: Oxford University Press; 2015.

4. Applebaum AJ, Stein EM, Lord-Bessen J, Pessin H, Rosenfeld B, Breitbart W. Optimism, social support, and mental health outcomes in patients with advanced cancer.

Psychooncology. 2014;23(3):299-306.

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ASK A PHARMACIST

Pregnancy Screening During Chemotherapy What kind of pregnancy testing should be done in women of childbearing potential who are receiving chemotherapy?

— Name withheld on request

Many cancer treatments may cause harm or death to a developing fetus if exposure occurs during pregnancy. Although cancer treatments may temporarily reduce a woman’s ability to become pregnant, these effects are variable and should not be relied upon to prevent pregnancy.

One important step is counseling the patient about the risks if she were to become pregnant while receiving chemotherapy. These include potential harm to the fetus as well as the mother (eg, providers may not be able to

perform all necessary imaging; certain medications are contraindicated during pregnancy). Depending on the treatment elected, birth control requirements may be quite strict. Some clinical trials require patients to use 2 methods of birth control during treatment and to continue birth control use for months after the completion of treatment.

Patient-specific factors such as cancer type, past medical history, religious beliefs, and personal preferences should also be taken into account. For example, hormonal contraceptive products may need to be avoided in a patient with an estrogen-sensitive breast cancer. Consultation with a gynecologist may be helpful.

The National Comprehensive Cancer Network (NCCN) recommends that these conversations (as well as discussion of fertility preservation options, if desired) occur prior to the initiation of cancer treatment. This information should be documented in the medical record, as well as included in any informed consents.

There are no current guidelines with specific recommendations for pregnancy testing; thus each institution should set their own policy. Here are some points to consider: • Should a pregnancy test be required prior to starting treatment? Is there a certain time frame that this result should be noted? For example, some institutions require that the negative

•

• •

•

pregnancy test be within 72 hours before the patient’s treatment.

Should a pregnancy test be required at regular intervals during treatment?

Practices vary between institutions, with some checking prior to each dose of chemotherapy and others checking at less frequent intervals or not at all.

What method of testing should be used? Notably, serum HCG tests are more sensitive than urine HCG tests.

How should women of childbearing potential be identified? Age, history of sterilizing surgeries (eg, hysterectomy), and menstrual status should be taken into account.

Are there any systems or process alerts that can be used to ensure the agreed upon testing is performed? ■

Let us answer your questions!

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

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

36 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2019 • www.OncologyNurseAdvisor.com

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