Oncology Nurse Advisor May/June 2019 by Haymarket Media

www.OncologyNurseAdvisor.com

May/June 2019

RADIATION & YOUR PATIENT

FEATURE Increased Risk for MHDs Seen With Head and Neck Cancers

Radiotherapy in Children: Reducing the Risks of Late Effects to the Spine

JOURNAL REVIEW Nurse Study Calls for Better Use of Protective Equipment

COMMUNICATION CHALLENGES Using Courage in Your Practice The SIOPE working group recommendations include lower doses that target fewer vertebrae in young children.

THE PATIENTâ&#x20AC;&#x2122;S VOICE Navigation Through Prostate Cancer Treatment

ASK A PHARMACIST Desensitization of Medication

THE TOTAL PATIENT

PRSRT STD US POSTAGE PAID PONTIAC IL PERMIT #60

Managing AEs of Breast Cancer Treatment With SelfAcupressure

Time-saving clinical tools for patient-centered care. OncologyNurseAdvisor.com provides all of the tools you need to better care for your patients. • Cancer treatment regimens

• Easy-to-use medical calculators

• Downloadable patient fact sheets

• Comprehensive drug slideshows

Visit www.OncologyNurseAdvisor.com today.

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: https://info.wrightsmedia.com/licensing-reprints-request Permissions: www.copyright.com Unless otherwise indicated, persons appearing in photographs are not the actual individuals mentioned in the articles. They appear for illustrative purposes only.

Oncology Nurse Advisor (ISSN 2154-350X), May/June 2019, Volume 10, Number 3. 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 • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 1

CONTENTS 4

May/June 2019

IN THE NEWS • Toolbox Enables Quick Response to Anticancer Therapy-Induced Hypersensitivity Reactions • Using Harm Reduction to Mitigate Opioid Addiction in Patients With Cancer • Addition of CHG-Impregnated Dressing Dramatically Changes CLABSI Rate • Seasonal Influenza Vaccine Safe in Patients Receiving Immunotherapy

• Baseline Pain Scores Predictive of Post Radiotherapy Pain in Breast Cancer • Patients’ Responses Regarding Discontinuing TKI Therapy for CML Are Mixed … and more

ONCOLOGY NURSE ADVISOR FORUM • A New Threat From E-cigarettes • Guidelines for Flushing IV Lines Between Medications

NAVIGATOR NOTES Dual Role of Oncology Pharmacists in Cancer Care Teams Tiffany Garbutt, PhD

31 FIND US ON

FEATURE Increased Risk for MHDs Seen With Head and Neck Cancers Megan Garlapow, PhD

OncologyNurseAdvisor.com

@ONAcom

linkedin.com/company/oncology-nurse-advisor

2 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

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

www.OncologyNurseAdvisor.com

FEATURE ARTICLE Pediatric Oncology Intervention Focuses on a Common Adverse Effect of Nursing

An evidence-based intervention sought to improve compassion fatigue, compassion satisfaction, and resilience and coping practices among pediatric oncology nurses. Bette Weinstein Kaplan

ISSUES IN CANCER SURVIVORSHIP 18

JOURNAL REVIEW Nurse Study Calls for Better Use of PPE Among Nurses John Schieszer

RADIATION & YOUR PATIENT Radiotherapy Poses Risks for Children’s Spinal Development

Using Survivorship-Specific Exercise Programs to Help Patients Increase Their Daily Activity

A group of researchers explored the value of using an exercise program designed for cancer survivors to help them increase their daily activity levels. Bette Weinstein Kaplan

Bryant Furlow

FROM CANCERCARE 28

COMMUNICATION CHALLENGES Using Courage in Your Practice Ann J. Brady, MSN, RN-BC, CHPN

How to Support Positive Body Image and High Self-Esteem in Patients

The impact of treatment adverse effects on self-esteem and what nurses can do to help. Leeann Medina-Martinez, LMSW

THE TOTAL PATIENT Managing Fatigue and Other Adverse Effects of Breast Cancer With Self-Acupressure Bette Weinstein Kaplan

FACT SHEETS Alcohol and Cancer Risk

This fact sheet examines how alcohol consumption can affect cancer risk. PUBLISHERS’ ALLIANCE: DOVE PRESS

FROM CANCERCARE Easy Meditation Practices for Patients and Caregivers Richard Dickens, LCSW-R

A review of 14 cases in which patients with WDTC experienced adverse outcomes after surgical treatment.

THE PATIENT’S VOICE Help on a Hard Road

Cancer Management and Research

Lee Hillstrom

ASK A PHARMACIST Graduated Doses; Efficacy of Generics Lisa A. Thompson, PharmD, BCOP

Does Every Classical Type of Welldifferentiated Thyroid Cancer Have Excellent Prognosis? A Case Series and Literature Review

ON THE

WEB

www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 3

IN THE NEWS Toolbox Enables Quick Response to Anticancer Therapy-Induced Hypersensitivity Reactions Use of hypersensitivity toolboxes containing the necessary medications and appropriate administration supplies enables quick nurse response to anticancer therapy-induced hypersensitivity, according to results of a study presented at the Oncology Nursing Society (ONS) 44th Annual Congress, held in Anaheim, California. For this study, the investigators developed a multidisciplinary subgroup within the Anticancer Therapy Council to improve response practices. The subgroup identified variations in hypersensitivity response processes across their network and conducted time trials to identify a best practice for obtaining necessary medications and administration supplies. The time-trial study compared the following processes: No toolbox Necessary drugs are obtained individually from an automated dispensing cabinet (ADC) and the necessary supplies for administration are obtained from a supply room or work station on wheels (WOW). ADC hypersensitivity drug trigger Selecting hypersensitivity in the ADC opens hypersensitivity protocol-specific medication drawers and appropriate administration supplies are obtained from the supply room or WOW. ADC hypersensitivity toolbox Selecting hypersensitivity in the ADC provides a nurse with a toolbox containing all hypersensitivity medications, needed supplies, and a treatment algorithm as a reference. Emergency medication toolbox A tackle box containing medications and supplies needed to respond to emergency situations in a clinical setting, including hypersensitivity-designated medications and supplies, is obtained from a locked room or cabinet. The emergency medication toolbox is not kept in the ADC. The time trials involved 3 different nurses completing each process, and the researchers calculated an average of the time each practice took to complete. Each time trial started 30 feet from the ADC or toolbox storage location; the nurse had to obtain all medications and appropriate administration supplies per the Hypersensitivity Protocol SOP. The time trial started when the nurse left the start position to obtain the medication and supplies, and stopped when the nurse returned to the start position. No nurse coaching was permitted. The average times for each method were 3.15 minutes for no toolbox, 2.03 minutes for ADC hypersensitivity drug trigger, and 1.04 minutes for both the ADC hypersensitivity toolbox and the emergency medication tool box.

Summary Tab in EMR Improves Pretransplant Patient Workup Coordination An easy-to-view page within patients’ electronic medical records (EMRs) that consolidates all the pertinent information gathered in pretransplant patient workups improves the efficiency of the stem cell transplantation coordination process

for both nurses and patients, according to a presentation at the ONS 44th Annual Congress. Extensive work-ups are required for patients prior to undergoing stem cell transplantation, including multiple tests, consultations, and patient education. Clinical nurse coordinators (CNCs) are usually charged with managing this process at large cancer institutions.

4 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

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

A baseline survey revealed that CNCs had to search through 5 different locations within the EMR for pertinent patient information, which can take at least 1 to 1.5 hours. Furthermore, most covering clinicians (87.5%) also reported difficulty in locating needed patient information. Therefore, Faye Inumerables, MSN, RN, ACNS-BC, OCN®, of Memorial Sloan-Kettering Cancer Center in New York City, and colleagues determined that an electronic tool to consolidate the complex pretransplant evaluations of these patients could improve the coordination of care. The team sought to create the clinical summary tab, a specialized view that consolidated all pertinent transplant patient information onto 1 page within the current EMR. Surveys conducted before and after implementation indicated a significant increase in ease of locating data. Prior to implementing the clinical summary tab, locating patient data was rated as “somewhat difficult” by almost 90% of respondents. In the postimplementation survey, less than 30% of respondents rated locating patient data as “somewhat difficult,” with more than 50% rating it as “easy” and approximately 25% rating it as “very easy.” Read more at https://bit.ly/2WG6dn1.

Using Harm Reduction to Mitigate Opioid Addiction in Patients With Cancer Opioid misuse, addiction, and diversion can afflict patients being treated for cancer and may complicate treatment. Healthcare providers in oncology must be ready to deal with the public health issues surrounding opioids. Harm reduction, a feasible approach to managing opioid misuse/ diversion in oncology patients, was discussed in a presentation at the ONS 44th Annual Congress. Successfully addressing the opioid epidemic is prompting a large-scale effort similar to that which has been deployed to deal with the epidemic of acquired immune deficiency syndrome (AIDS). Gretchen McNally, PhD, ANP-BC, AOCNP, of The Ohio State University James Cancer Hospital (Columbus, Ohio), describes addiction as a complex, multifactorial, chronic condition that is not just about drugs, but about what is happening in the brain. The principle behind harm reduction is to improve outcomes by reducing harm/minimizing risks of dangerous consequences regarding drug use. In the context presented by Dr McNally, harm reduction is not an attempt at abstinence, nor is it an active treatment for addiction, which is beyond

the scope of care provided by oncology clinicians — in this context, nurse practitioners, and physician assistants. Harm reduction strategies recognize that all patients are susceptible to drug misuse/diversion: Ask every patient about past, as well as current, substance use/addiction; use screening questionnaires and direct observation, patient/family history, clinical judgment, and urine toxicology screens. Red flags to watch out for include claims of lost or stolen pills or prescriptions, early requests for refills, visits with multiple prescribers, frequent ED visits, sharing medications, refusing urine toxicology screens, and requests for specific drugs or escalating doses. Prescribing practices to consider include use of prescription drug monitoring program (PDMP), have patients sign a controlled medicine management contract and complete a pain diary, limit prescription quantity, decrease the pill load (sustained vs immediate release), pill counts, and urine toxicology screens. Read more at https://bit.ly/2ViQzwo.

Addition of CHG-Impregnated Dressing Dramatically Changes CLABSI Rate Including chlorhexidine gluconate (CHG)-impregnated dressing in a standardized central line bundle resulted in a 100% decrease in central line-associated bloodstream infections (CLABSIs), according to results of a nurse-led intervention presented at the Use of dressing cut ONS 44th Annual Congress. CLABSI rate to 0. “Our oncology unit is a 26-bed solid oncology inpatient unit that cares for patients with cancer admitted for chemotherapy, symptom management, oncology emergencies, and neutropenic surveillance,” reported Samantha Thomas, BSN, RN, OCN®, of UCLA Medical Center in Santa Monica, California. The unit cares for patients with port-acaths (PACs), peripherally inserted central catheters (PICCs), and hemodialysis/plasmapheresis central lines. The nursing staff has a direct and critical role in preventing CLABSIs. CHG-impregnated dressings were not standard in the central line bundle, and the unit experienced 13 CLABSI cases between July 2016 and July 2017. In addition, the CLABSI rate was above national benchmark expectations in 8 of 13 months. The nursing team designed and conducted a trial on the oncology unit from August 2017 to December 2017. For the trial, unit nursing staff were instructed in placement and

www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 5

IN THE NEWS management of CHG-impregnated dressings, which were to be used on all central lines on the unit for the trial period. The number of CLABSIs on the unit during the trial period was 0; a 100% decrease in infections that outperformed the national benchmark. The success of the trial led to systemwide implementation of including a CHG-impregnated dressing in the central line bundle. Read more at https://bit.ly/2HiCdZ1.

were similar to those from published clinical trials involving patients unselected for influenza vaccination. Furthermore, in this subgroup, no significant differences were observed in the rates of new onset irAEs with respect to order of administration of influenza vaccine and immune checkpoint inhibitor. Based on these findings, the authors support the current recommendations of the ACIP for annual seasonal influenza vaccination in patients on ICI therapy. Read more at https://bit.ly/2VwFrAS.

Patients with cancer are at increased risk for influenza-related complications. Previous studies have shown that although patients receiving chemotherapy have an attenuated immune response to the influenza vaccine, the influenza-related immune response in Annual flu shot safe those undergoing immune checkpoint for patients on ICIs. inhibitor (ICI) therapy is similar to that observed in healthy persons. However, results from some recent studies have suggested that administering the influenza vaccine to patients also receiving an ICI may result in expansion of T cell clones that recognize both vaccine and self, thereby causing a high rate of immune-related adverse effects (irAEs). All 370 patients included in this study were treated with a PD-1 inhibitor (nivolumab or pembrolizumab) or a CTLA4 inhibitor (ipilimumab) for advanced cancer — mostly lung cancer or melanoma — at the Memorial Sloan-Kettering Cancer Center, in New York City. These patients received inactivated influenza vaccine within 65 days of any dose of immune checkpoint inhibitor therapy, either before or after ICI administration. The study was conducted over 3 consecutive flu seasons (2014-2015, 2015-2016, and 2016-2017). A subgroup of 170 of these patients who were newly treated with a PD-1 inhibitor (and vaccinated against influenza within 65 days of therapy) was also evaluated separately and compared with results of historical controls from published clinical trials. In the full patient cohort, the rate of any grade new-onset irAEs, occurring after administration of both immune checkpoint inhibitor and influenza vaccine, was 20%; 8% of patients experienced a grade 3-4 irAE. No grade 5 irAEs were observed. Similarly, results obtained for the subgroup of patients newly treated with a PD-1 inhibitor showed rates of all-grade and grade 3-4 irAEs of 18% and 7.6%, respectively. The study authors noted that the rates and severity of irAEs reported for this subgroup

Intervention Improves EOL Conversations Between Patients and Clinicians Most conversations between patients with terminal cancer and clinicians related to patient goals reportedly occur in the month preceding the patient’s death, in acute care settings, and were not between the patient and their oncology care provider. Barriers to the provision of high-quality conversations related to the end of life include inadequate clinician training in communication skills, clinician time constraints, patient anxiety, clinician uncertainties about appropriate timing or patients’ readiness to discuss these issues, ambiguous responsibility among clinicians for holding a conversation, and inadequate system to support clinicians in eliciting and documenting patient goals. For this study, the intervention arm incorporated a communication quality-improvement intervention for clinicians that included a clinical tool (a structured communication tool called the Serious Illness Conversation Guide), clinician training (a 2.5-hr, skills-based, palliative care faculty-led training session and follow up), and system changes (an electronic medical record [EMR] documentation template based on the communication guide and timely distribution of the communication guide to the clinician prior to patient visit). Although clinicians in the control group were aware of the communication guide and template, they did not receive any training in their use. The clinician-provided communication intervention along with usual care (the control) were evaluated in clusters at a specific disease center within the Dana-Farber Cancer Institute in Boston and 2 affiliated satellite clinics from September 2012 to June 2016. Patients were identified for the study by clinicians in both study arms and were considered eligible if they were aged 18 years or older and their clinician answered “No” to the question: “Would you be surprised if this patient died in the next year?” Patient-clinician interactions occurred in an outpatient setting, and patients were blinded to study arm. Only patients who died within 2 years of study enrollment were included in the analysis.

6 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

Seasonal Influenza Vaccine Safe in Patients Receiving Immunotherapy

Primary end points were goal-concordant care and peacefulness at the end of life, which were reported in a separate paper. Secondary end points included documentation of at least 1 serious illness conversation before death; timing of the initial conversation before death; quality of conversations; and documentation accessibility in the EMR. Data related to these end points were abstracted from a review of patients’ EMR after patient death by 2 trained, blinded researchers who performed independent evaluations. Ninety-one clinicians were randomly assigned (1:1) to the intervention or control arm; of these, 76 had participating patients who died (161 patients) and were included in the analysis. Significantly higher rates of documented end-oflife (EOL) conversations were observed in the intervention group compared with the usual care group (96% vs 79%; P =.005). Furthermore, compared with the usual care group, these conversations occurred earlier in the intervention arm (median, 143 days vs 71 days; P <.001), and documentation indicated greater focus on values or goals (89% vs 44%; P <.001), prognosis or illness understanding (91% vs 48%; P <.001), and life-sustaining treatment preferences (63% vs 32%; P =.004) in the intervention arm. Although documentation about end-of-life care planning did not differ significantly when the 2 study arms were compared (80% [intervention] vs 68% [control]; P =.08), more patients in the intervention arm had documentation that was accessible in the EMR (61% vs 11%; P <.001). Read more at https://bit.ly/2VwZNda.

Baseline Pain Scores Predictive of Post Radiotherapy Pain in Breast Cancer Baseline pain scores are the strongest predictor of pain following radiotherapy in patients with breast cancer, according to a presentation at the AACR 2019 Annual Meeting in Atlanta, Georgia. Other factors associated with postradiotherapy pain included Fractionation also a age, body mass index (BMI), current significant risk factor smoking status, radiotherapy fractionation, and use of pain medication. In this prospective, longitudinal study of 1000 patients with breast cancer enrolled between 2011 and 2013, researchers assessed risk factors for developing pain in women undergoing adjuvant radiotherapy. The Brief Pain Inventory, with an 11-point numeric rating scale between 0 and 10, was used

to determine the average of 4 different pain severity items at baseline and after radiotherapy. At baseline, the average pain score was 1.5 (±1.0), and it rose to 2.5 (±1.8) following radiotherapy. Multivariable linear regression analysis on data from 863 patients indicated postradiotherapy pain scores associated with baseline pain score (β = 0.39 per 1 point increment; P <.0001), age (β = –0.03 per 1 year increment; P <.001), BMI (β = 0.03 per 1 kg/m2 increment, P =.004), current smoking status (β = 0.57, P =.022), conventional radiotherapy fractionation (β = 0.48, P =.033), and use of pain medication (β = 1.85, P <.0001). Additional stratification of analyses showed that radiotherapy fractionation is a significant risk factor for postradiotherapy pain only in patients who experienced more pain. Identification of risk factors for postradiotherapy pain could help identify patients at high risk and guide decisions on treatment regimens and approaches, particularly as cancer- and treatment-related pain can affect quality of life in cancer survivors. Read more at https://bit.ly/2LBgEqD.

Thromboembolic and CVD Mortality Risk Factors in Multiple Myeloma In patients with multiple myeloma (MM), gender, age, marital status, tumor grade, and surgery were significant risk factors for death via thromboembolic and cardiovascular diseases (CVDs), according to results from a population-based study presented recently at the AACR 2019 Annual Meeting in Atlanta, Georgia. Patients with MM are at a higher risk for cardiovascular and thromboembolic events, so researchers used the SEER database to assess data from 55,991 patients with multiple myeloma to analyze cardiovascular and thromboembolic mortality risk in these patients. A total of 4510 deaths by cardiovascular and thromboembolic events occurred. Analyses revealed the hazard ratio (HR) for death via thromboembolic and cardiovascular diseases as a patient with MM was 1.39 for male patients (P =.005), 1.07 for increased age (P =.005), and 0.81 for being married (P =.0014). Tumor grade and surgery were also significant risk factors for death. The 4 cardiovascular and thromboembolic diseases resulting in death in patients with MM were atherosclerosis (88), heart disease (3799), aortic aneurysm and dissection (39), and cerebrovascular disease (1861). In addition, the higher the grade of MM, the lower the survival probability (P <.001). Read more at https://bit.ly/2WFlt3B. In the News continues on page 8

www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 7

IN THE NEWS

Lifelong oral tyrosine kinase inhibitor (TKI) therapy is considered the standard-of-care treatment for patients with chronic phase chronic myeloid leukemia (CML); however, recent evidence has shown that some patients with deep and long-lasting molecular responses Relapse, other risks to TKI therapy can discontinue treatare misunderstood ment. Furthermore, this option for select patients has now been incorporated into CML treatment guidelines. Although a number of previous studies have explored whether patients with CML receiving TKI therapy would be willing or expect to discontinue TKI therapy in the future, this study used in-depth qualitative methods to investigate specific factors that patients consider important in making this decision, as well as their understanding of the likelihood of achieving a treatment-free remission. This semi-structured qualitative study was conducted via 20-minute telephone interviews that were audio recorded, transcribed, and analyzed through team-based systematic content analysis. Specific questions were posed to patients about their experiences related to CML diagnosis and treatment, and why they would or would not consider TKI discontinuation; questions designed to assess patient knowledge concerning discontinuation of TKI therapy were also included. Participants were a convenience sample of patients who were potential candidates for TKI treatment discontinuation, although an equal mix of patients who did or did not want to try TKI treatment discontinuation was deliberately included. These patients were recruited from 3 academic cancer centers that were participating in a multisite TKI discontinuation trial. Hence, most patients stated that they were familiar with the rationale for stopping TKI therapy. Patient education was provided for the small group of patients unfamiliar with related study findings. Of the 22 adult patients with chronic phase CML included in the study, all were either eligible for TKI treatment discontinuation or had been undergoing TKI therapy for at least 1 year and had achieved a deep molecular response. All patients were age 40 years or older and had been receiving TKI therapy for a median of 7 years. Although most of the study participants stated that they had received counseling from their physicians on the risks and benefits of TKI treatment discontinuation, this study revealed misunderstandings on the part of patients regarding their risk of relapse, as well as other details related to TKI treatment

discontinuation. Those patients who did not want to stop TKI therapy more accurately described the risk of relapse. Read more at https://bit.ly/2LFBu8y.

Recognition and Early Management Critical With Adverse Reactions of CAR-T First approved by the US Food and Drug Administration (FDA) in 2017, chimeric antigen receptor T-cell (CAR-T) therapy has provided a very powerful tool for the treatment of a number of B-cell malignancies. Currently, two CAR-T therapies, tisagenlecleucel and axicabtagene ciloleucel, have been granted FDA approval. Both are modified autologous T-cell products directed against CD19, a surface antigen overexpressed on malignant B cells. Cytokine release syndrome (CRS) is a common, potentially life-threatening toxicity associated with CAR-T that occurs when cytokines, such as tumor necrosis factor alpha, interleukin-2, and interleukin-6, are systemically released in response to the activation and proliferation of CAR T-cells. The hallmark of CRS is high fever, with other possible symptoms including tachycardia, myalgias, and fatigue; organ dysfunction is a possible clinical sequelae. CAR-T has also been commonly associated with development of neurologic toxicity, also referred to as CAR-T related encephalopathy syndrome and immune effector cell-associated neurologic toxicity syndrome. The pathophysiology of CAR-T related neurotoxicity is less well understood, although elevated cytokine levels and CAR T-cell penetration into the CNS may be involved. Symptoms of CAR-T related neurologic toxicity include decreased attention, disorientation, encephalopathy, anxiety, confusion, delirium, language disturbances, difficulties, aphasia, somnolence, ataxia, weakness, and seizures. Other potential adverse reactions to CAR-T include cytopenias, infection, hypogammaglobulinemia, and tumor lysis syndrome. Nursing management is critically important to recognizing the potential adverse effects and providing care coordination with timely escalation of care for patients undergoing CAR T-cell therapy. ■ Read more at https://bit.ly/2W0a80G.

8 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

For full news stories visit OncologyNurseAdvisor.com

Patients’ Responses Regarding Discontinuing TKI Therapy for CML Are Mixed

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

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

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

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.

A NEW THREAT FROM E-CIGARETTES We are seeing patients with a diagnosis of popcorn lung. What is it and what causes it? — Name withheld upon request Popcorn lung is actually bronchiolitis obliterans, which is scarring of the smallest air sacs of the lung. It is a serious lung disease that causes coughing, wheezing, and shortness of breath, similar to COPD. The disease was first noted more than a decade ago in factory workers where microwave popcorn — thus the name — was manufactured. The workers were breathing in diacetyl, among other contaminants. Diacetyl is a chemical used to create buttery flavor in foods such as popcorn and caramel. More recently, popcorn lung is being diagnosed in people who use fl avored e-cigarettes. Some e-cigarette companies are using diacetyl to enhance flavorings of vanilla, maple, coconut, and others. Although diacetyl was removed from microwave popcorn and other food items, its current use results in direct exposure to the lungs through inhalation. — Rosemarie A. Tucci, RN, MSN, AOCN

GUIDELINES FOR FLUSHING IV LINES BETWEEN MEDICATIONS The topic of how long to flush IV lines between noncompatible chemotherapeutic medications was brought up at a team meeting at our outpatient infusion center. Are there any published studies regarding the required amount to use to flush a line before the next medication can be hung? — Name withheld on request Guidelines related to the required amount of normal saline solution (NSS) to flush a line between medications vary and appear to be institution-based. The only consistency in the literature is that all lines should utilize a 10-mL syringe to preserve the patency and functionality of the catheter in adult patients and 3 mL for pediatric patients. The California Department of Health Care Services recommends flushing the IV line between medications based on the type of line (ie, PICC vs Groshong). These guidelines suggest flushing the line with as little as 3-10 mL NSS after antibiotics and with as much as 20 mL after total parenteral nutrition (TPN). Use of heparin is per institution guidelines and physician order. Review of the Institute for Safe Medication Practices provides very few standards for the amount for flushing, but does endorse the use of a 10-mL syringe. — Jiajoyce R. Conway, DNP, CRNP, AOCNP

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

www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 9

NAVIGATOR NOTES Dual Role of Oncology Pharmacists in Cancer Care Teams Tiffany Garbutt, PhD

symptom management, supportive care, to even survivorship programs after treatment completion.2 BCOPs meet with patients shortly after their diagnosis to learn more about their unique circumstances, including nutritional needs and current medications. Based on this information, they determine the risk of drug interactions and develop a patientspecific treatment plan. “Then we go over with the patient what we’re prescribing, what it’s for, how to take it, how long they’re going to take it, any side effects they might have from it, and we also touch on adherence,” explained Megan May, PharmD, BCOP, an oncology pharmacist at the Cancer Care Center at Baptist Health Lexington in Kentucky.4 Oncology pharmacists provide a complete set of educational materials to the patient regarding their medication and prescribed administration schedule.1 LITERATURE SUPPORT FOR PHARMACISTS

DEFINING THE ROLE OF ONCOLOGY PHARMACISTS

BCOPs are involved with patient care at all stages from diagnosis, to treatment decisions, medication management,

In one reported case, including oncology pharmacist consultations as part of a multidisciplinary consultation program before the start of a new oral anticancer therapy improved patient support and treatment. These consultations revealed that 24% of patients needed additional help from a caregiver to take their medication. Additionally, they revealed the prescribed medication had drug interactions in 36% of patients, 4 of whom required a different drug. Altogether, the information delivered by oncology pharmacists improved the ability of local community pharmacists to advise patients by 83%.6

Information delivered by oncology pharmacists improved the ability of community pharmacists to advise patients by 83%. 14 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

ancer treatment is slowly transitioning away from intravenous drug delivery to oral therapy allowing for more opportunities to improve how drugs are prescribed, dispensed, and monitored. Board certified oncology pharmacists (BCOPs) are in a unique position to improve patient care in each of these areas.1 Oncology pharmacists are often regarded as cancer medication experts and have extensive training in medication management and education.2 This unique knowledge set combined with expertise in patient care allows BCOPs to serve as both a resource for multidisciplinary cancer care teams and as a liaison for patient needs. A recent study has shown that incorporating oncology pharmacists helps to improve capacity, breath, and efficacy, as well as reduce the number of oncology patient visits.3 “The oncology pharmacist is often one of the few team members who fully understands the safety, efficacy, pharmacologic, and financial components of patient care,” said Michael Bourisaw, executive director of the Hematology/Oncology Pharmacy Association.4 On a multidisciplinary team, pharmacists provide up-to-date information and educational materials to their fellow team members about cancer medication, potential drug interactions, and side effects.5 Most importantly, oncology pharmacists are on the frontlines of patient care and are responsible for relaying information to the team about the patient’s response to certain medications and their needs.

In most cases oncology pharmacists will continue to meet and monitor the patient throughout the treatment course to assess and mitigate potential adverse effects. This helps to build a relationship between pharmacists and their patients and can prove key to identifying and maintaining medication adherence. According to one study, the addition of oncology pharmacists to a multidisciplinary lung cancer treatment team led to significant improvements in patient medication adherence. Oncology pharmacists identified 154 cases in which patients did not adhere to their medication, 43.5% of which placed the patient at high risk. This allowed healthcare providers to intervene in a timely manner, thereby decreasing unplanned admissions and clinic visits.7 Oncology pharmacists can also help patients in identifying and mitigating barriers to medication access. In one case, a patient with prostate cancer was prescribed a drug with a co-pay of $2196 per month. Upon hearing the news, the pharmacist worked with the multidisciplinary team’s financial advisor to identify a $6500 grant that reduced the drug’s co-pay to $500. “We keep a running log, and as that grant money starts to trickle down and run out, we start the same process all over, looking at grants to see if anything has opened up that we can apply for. If not, we’ll reach out to the manufacturer for assistance,” said Jeanie Patrick,

PharmD, BCOP, also an oncology pharmacist at Cancer Care Center.4 On multidisciplinary teams, BCOPs are relied heavily upon by the clinical team for their expertise in cancer medicine and for the vital patientspecific information they provide. They are knowledgeable, collabora-

REFERENCES 1. Mackler E, Segal EM, Muluneh B, Jeffers K, Carmichael J. 2018 Hematology/Oncology Pharmacist Association best practices for the management of oral oncolytic therapy: pharmacy practice standard. J Oncol Pract. 2019;15(4):e346-e355. 2. The role of hematology/oncology pharmacists. HOPA Hematology/Oncology

BCOPs can help patients identify and mitigate barriers to medication access.

Pharmacy Association website. http:// www.hoparx.org/images/hopa/advocacy/ Issue-Briefs/HOPA-_About_Hem_Onc_ Pharmacist_Issue_Brief.pdf. Approved August 22, 2014. Accessed May 6, 2019. 3. Ignoffo R, Knapp K, Barnett M, et al. Boardcertified oncology pharmacists: their potential contribution to reducing a shortfall

tive team players that play a key role in leading evidence-based decisions to improve patient care.2 Oncology pharmacists are also heavily relied upon by their patients for a level of personalized health care and guidance that makes cancer treatment just a little bit easier for all involved. “I was not only working to the top of my ability, but I knew the appreciation that the patient felt for me and my role. It was an amazing experience to have as any type of healthcare professional,” said Kristen Rychalsky, PharmD, BCOP, an oncology pharmacist at Smilow Cancer Hospital at Yale New Haven in Connecticut.4 ■

in oncology patient visits. J Oncol Pract. 2019;12(4):e359-e368. 4. Duff BL. What it’s like to be an oncology pharmacist. Drug Topics. https://www. drugtopics.com/clinical-pharmacology/ what-its-be-oncology-pharmacist. Accessed May 6, 2019. 5. Ma CSJ. Role of pharmacists in optimizing the use of anticancer drugs in the clinical setting. Integr Pharm Res Pract. 2014;2014(3):11-24. 6. Streicher C, Daulange A. Implementation of pharmacist consultations as part of a multidisciplinary consultation program for patients with oral anticancer agent: a descriptive study. Eur J Oncol Pharm. 2018;1(2):e0003. 7. Walter C, Mellor JD, Rice C, et al. Impact of a specialist clinical cancer pharmacist at a

Tiffany Garbutt is a medical writer based in Cary, North Carolina.

multidisciplinary lung cancer clinic. Asia Pac J Clin Oncol. 2016;12(3):e367-e374.

Oncology Nurse Advisor Newsletters keep you involved in all the action on OncologyNurseAdvisor.com Get Oncology Nurse Advisor delivered to your inbox. Sign up at OncologyNurseAdvisor.com/newsletters to get our next mailing! www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 15

FEATURE | Head and Neck Cancer

Increased Risk for MHDs Seen With Head and Neck Cancers Mental health disorders (MHDs) may be an adverse effect of head and neck cancer diagnosis, treatment, or treatment morbidities. MEGAN GARLAPOW, PHD

he presence of cancer can impact a patient’s mental health, and in turn, prognosis can be influenced by a patient’s mental state.1,2 Results of a new study shed light on significant relationships between head and neck cancer (HNC) diagnoses and mental health disorders (MHDs).3 The study was a retrospective cohort analysis of the Truven Health MarketScan Commercial Claims and Encounters database records from 52,641 patients, conducted by researchers Ji Hyae Lee, BA, and colleagues from Pennsylvania State University, in Hershey.3 In this study, the researchers explored relationships between head and neck cancers and the presence of mental health disorders prior to and following the HNC diagnosis. Patients were included for whom data were available for at least 1 year prior to diagnosis of a head and neck cancer. The period of time considered for postdiagnosis mental health disorders was between 90 days and 1 year after diagnosis of a head and neck cancer. Mental health disorders were identified by many possible mental health diagnoses and/or prescriptions for psychotropic treatments.3

Disfigurement and other morbidities as a result of HNCs and their treatment increase patients’ risk of depression

IMPACT OF TREATMENT MORBIDITIES Among cancers, HNC has been shown to be associated with high rates of depression.4 According to Lee and colleagues, although treatments can be effective against head and neck cancers, “treatment morbidities can include disfigurement, dysphagia,

16 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

dysarthria, and tracheostomy and gastric tube dependence, all of which can significantly affect quality of life.”3 The greatest impact on mental health disorders appeared to relate to treatment for head and neck cancer. Patients who were treated with a combination of surgery, chemotherapy, and radiotherapy were much more likely to develop mental health disorders than were patients treated with only surgery (adjusted odds ratio [OR], 3.69; 95% confidence interval [CI], 3.44-3.96).3 Overall, patients with HNC showed an increase in mental health disorders following cancer diagnosis, rising to a rate of 29.9% after diagnosis, compared with 20.6% prior to diagnosis. The authors noted that the rate prior to diagnosis was near to the national estimated average of 17.9% but was somewhat higher.3 Women showed a higher tendency to develop mental health disorders following HNC diagnosis than men did (adjusted OR, 1.58; 95% CI, 1.49-1.67). Other characteristics associated with developing an mental health disorder after HNC diagnosis were alcohol use (adjusted OR, 1.56; 95% CI, 1.38-1.76) and a history of using tobacco (adjusted OR, 1.42; 95% CI, 1.34-1.50).3 INCIDENCE OF MHDS BY CANCER TYPE A result that the researchers had not anticipated was that tracheal cancer showed a high unadjusted OR for mental health disorders of 2.11 (95% CI, 1.87-2.38) vs that for oral cavity cancer. The most prevalent head and neck cancer in the study was oral cavity cancer, at 40.4% of cases.3 Cancers of the nasopharynx and hypopharynx also showed a higher association with mental health disorders than oral cavity cancer did. Compared with oral cavity cancer, cancer of the nasopharynx showed an unadjusted OR of 1.22 (95% CI, 1.14-1.31), and cancer of the hypopharynx showed an unadjusted OR of 1.21 (95% CI, 1.10-1.33). Laryngeal cancer did not show an elevated prevalence of mental health disorders.3 A matched-cohort study that was conducted in Sweden, and included patients with any cancer diagnosis, showed that mental health disorders became elevated during the year before cancer diagnosis. In that study, at half a year prior to cancer diagnosis the hazard ratio (HR) for MHDs was 1.8 (95% CI, 1.7-1.9), with the HR peaking a week after diagnosis at 6.7 (95% CI, 6.1-7.4). The rate of mental health disorders also remained elevated for years after cancer diagnosis.1 Regarding increased levels of mental health disorders in the period leading up to a cancer diagnosis, the authors of the Swedish study suggested that the diagnostic process itself, in addition to symptoms of cancer and possible paraneoplastic

syndromes, can contribute to a higher prevalence of MHDs just before a cancer diagnosis.1 A separate study specifically examining depression in patients with HNC showed that worse depression severity was related to shorter survival (HR, 0.868; 95% CI, 0.819-0.921). Patients with more severe depression were also more likely

A Swedish study suggested that the diagnostic process itself can contribute to a higher prevalence of MHDs just before a diagnosis. to interrupt chemoradiation treatment (OR, 0.865; 95% CI, 0.774-0.966) and to show a worse treatment response (OR, 0.879; 95% CI, 0.803-0.963). In this study, treatment interruption was not strongly correlated with treatment response.2 CONCLUSION Beyond the important effects on quality of life, the relationship between mental health and treatment outcomes in patients with HNC makes this a critical aspect of a patient’s condition that should be monitored.2, 3 From their study of a large number of patient claims, the results by Lee and colleagues demonstrated that treatment for head and neck cancer is associated with development of mental health disorders, in addition to the risks posed by other patient characteristics. “Individualized care may help recognize and address the sociodemographic variables affecting mental health of the patients with [head and neck cancer],” they stated.3 ■ Megan Garlapow is a medical writer based in Tempe, Arizona. REFERENCES 1. Lu D, Andersson TM, Fall K, et al. Clinical diagnosis of mental disorders immediately before and after cancer diagnosis: a nationwide matched cohort study in Sweden. JAMA Oncol. 2016;2(9):1188-1196. 2. Zimmaro LA, Sephton SE, Siwik CJ, et al. Depressive symptoms predict head and neck cancer survival: examining plausible behavioral and biological pathways. Cancer. 2018;124(5):1053-1060. 3. Lee JH, Ba D, Liu G, Leslie D, Zacharia BE, Goyal N. Association of head and neck cancer with mental health disorders in a large insurance claims database [published online February 28, 2019]. JAMA Otolaryngol Head Neck Surg. doi: 10.1001/jamaoto.2018.4512 4. Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr. 2004;(32):57-71.

www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 17

JOURNAL REVIEW

reater efforts are needed to protect oncology nurses from an “invisible threat” in the form of hazardous drug exposure, according to researchers at the University of Michigan. They conducted a study in which they sought to improve nurses’ handling of chemotherapy by delivering an educational intervention with quarterly reminders and tailored messages. However, despite the intervention, it did not increase use of protective gear.1 The results from the study, which were published in Oncology Nursing Forum, suggest that new training programs on chemotherapy safety for nurses and pharmacists are urgently needed. “Nurses need to know that exposure to these drugs, either through spills or indirect exposure like surface contamination, put them at risk for both acute and chronic health problems,” said lead study author Christopher R. Friese, PhD, RN, professor of nursing and professor of health management and policy at the University of Michigan, Ann Arbor.

THE STUDY Exposure to chemotherapy occurs when health care workers inhale vapors or touch contaminated surfaces. Numerous studies have linked the handling of hazardous drugs to a variety of health problems, including reproductive issues, incidences of rare cancers, and a variety of respiratory and skin conditions.

Nurse Study Calls for Better Use of PPE Among Nurses John Schieszer

Dr Friese said unlike a needle stick, where a nurse is immediately aware of the serious health risks, the threat from chemotherapy exposure is subtle. Current guidelines recommend protective gear including double gloves, eye protection, and respirators. The randomized trial included nurses from 12 ambulatory cancer programs. In one arm, nurses received one-hour educational modules about personal protective equipment (PPE) with tailored messaging addressing some of the reported barriers to use. All the participants were asked to report chemotherapy drug spills and submit plasma samples for analysis. Those in the control arm only received educational modules. Among the 439 nurses eligible to participate, 415 (95%) enrolled in the study. The researchers assigned 189 nurses to the treatment arm and 226 nurses to the control arm. Among the participants, 378 (91%) completed the baseline survey

and 257 (62%) completed the baseline and primary end point surveys (121 participants in the treatment arm and 136 participants in control arm). WHAT WAS LEARNED After two years of the program, the researchers found little difference in the use of PPE between the two groups and no change over the course of the study. The researchers cite several possible reasons the intervention was not successful, including the quality of the content and technology barriers that may have made watching the video modules difficult. Dr Friese said another issue is that the protective devices are cumbersome. Nurses report that the gear is hot, uncomfortable, and it can be difficult to safely apply and use. The researchers propose undertaking new efforts to develop better PPE that is easy to use, affordable, and protective against hazardous drug exposure. They also call for collecting data through a registry to identify and track the health risks from exposure. A previous study by Friese and colleagues found that nearly 17% of nurses who work in outpatient chemotherapy infusion centers said they had been exposed to chemotherapy on their skin or eyes. IMPLICATIONS FOR NURSES Dr Friese suggests nurses should work together and with their managers to be sure that policies and procedures conform to the latest recommendations from the Oncology Nursing Society,

A greater number of oncology nurses need to work with their practice leaders to be sure their preparation and administration policies and procedures conform to evidence-based guidelines. 18 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

the National Institute for Occupational Safety and Health, and the United States Pharmacopeia. Nursing practice is somewhat safer today because drug preparation activi-

Nurses must be vigilant about reporting unsafe conditions. ties are centralized to dedicated areas with biological safety cabinets and increased use of closed-system transfer devices (CSTDs). Yet in 2019, some

oncology nurses still “mix” chemo and some in the field question the efficacy of CSTDs. “We also have no registry to track exposures and health effects attributed to exposures. I conduct research but also continue to staff an inpatient unit and take care of patients on chemo. I want to let my nurse colleagues know this is still a concern and that they need to protect themselves,” Dr Friese told Oncology Nurse Advisor. A greater number of oncology nurses need to work with their practice leaders to be sure their preparation and administration policies and procedures conform to evidence-based guidelines. Dr Friese said nurses must be vigilant about reporting unsafe conditions to

their leaders and take other steps. “They need to encourage their peers to protect themselves when handling hazardous drugs. Our work suggests that fellow nurses influence an individual nurse’s decision to wear PPE. We have to protect each other, and that starts with protecting yourself.” ■ John Schieszer is a medical reporter based in Seattle, Washington. REFERENCE 1. Friese CR, Yang J, Mendelsohn K, McCullagh MC. Randomized controlled trial of an intervention to improve nurses’ hazardous drug handling. Oncol Nurs Forum. 2019;46(2):248-256.

Time-saving clinical tools for patient-centered care. OncologyNurseAdvisor.com provides all of the tools you need to better care for your patients. • Cancer treatment regimens • Downloadable patient fact sheets

• Easy-to-use medical calculators • Comprehensive drug slideshows

Visit www.OncologyNurseAdvisor.com today. www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 19

RADIATION & YOUR PATIENT

Radiotherapy Poses Risks for Children’s Spinal Development Bryant Furlow With advances in highly conformal externalbeam radiotherapy (EBRT) and steep radiation dose gradients, radiosensitive tissues can be better spared exposure to ionizing radiation and resulting toxicities. New practice recommendations by a working group of pediatric radiation oncologists from across Europe emphasize the importance of radiation dose distributions involving spinal vertebrae as a risk factor for spinal development problems and identify ways to minimize risk. But more research is urgently needed and the authors called for multicenter clinical studies to better identify optimal vertebral radiotherapy dose distributions in children treated for cancer.

nhomogeneous radiation dose distributions across children’s developing vertebrae during cancer treatment can alter local gene expression, metabolism, endocrine signaling, and ultimately, normal spinal development, leading to spinal cord hypoplasia or growth restriction and problems such as scoliosis, kyphosis (the pronounced outward spinal curvature that causes back hunching), and lordosis (inward spinal curvature).1 The spine of newborns is only approximately 30% ossified. Vertebral ossification begins in the vertebral body and the dorsal halves of the vertebral arch, and as ossification progresses throughout early childhood, it displaces cartilage outward.1 By age 16 years, secondary ossification of vertebral body rim begins.1 Children with neuroblastomas, medulloblastomas, and other brain or spine cancers frequently undergo craniospinal EBRT.1,2 Because children’s bodies are smaller than those of adults, other radiotherapy-target organ volumes also are more frequently in closer proximity to their spines than is the case with adults.1 The incidence of some cancers is greater among young children (younger than 10 years for CNS tumors and younger than 5 years for renal tumors), for whom radiationassociated impairment of spinal development can be more marked.1 As early as 1973, researchers knew that pediatric radiotherapy dose could impact spinal growth, particularly among children receiving more than 35 Gy whole spine radiotherapy.1 In general, the younger the age of a patient at the time of irradiation, the more pronounced the potential long-term spinal development impacts can be. Infants (children younger than 1 year) are most affected. Radiotherapy for Wilms tumors earlier than age 1 year

20 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

is associated with adolescent growth restriction, with attained height decreases of up to 8 cm by age 15 years.1,3 “Radiation of extensive thoracic spinal segments can cause thoracic cage and lung underdevelopment, which considerably increases the risk of future respiratory insufficiency,” the investigators noted.1 Poor bone mass accumulation during development is also a risk factor for early-onset osteoporosis and bone fracture in adulthood.1,4 More recent advances in highly conformal and intensity-modulated EBRT delivery have improved the precision of radiation dose distributions and now better allow for more homogeneous dose delivery to vertebrae. But vertebral dose inhomogeneities do still occur and because of improving 5-year and long-term survival rates among children treated for cancer, the potential long-term quality-of-life impacts of spinal developmental disruptions are receiving more scrutiny.1 A NEED FOR GUIDELINES The need for clinical practice guidelines for children undergoing vertebral or perivertebral radiotherapy for cancer led the European Society for Paediatric Oncology’s (SIOPE) radiotherapy working group, representing radiation oncologists from 11 European countries, to undertake a review of the available evidence base.1 They published their consensus recommendations for managing pediatric vertebral radiotherapy dose in The Lancet Oncology.1 The consensus document emphasizes the importance of vertebral radiotherapy doses being homogeneously delivered to children — particularly among “children who have not yet finished the pubertal growth spurt,” reported lead investigator Bianca A. Hoeben, PhD, of the Department of Radiation Oncology

RADIATION & YOUR PATIENT at Radboud University Medical Center in the Netherlands, and colleagues.1 Pediatric radiation oncology teams “must consider late effects when planning radiotherapy of a spinal or paravertebral target volume,” the authors emphasized.1 “However, the severity of treatment-related damage is chal-

Recommendations can be used to inform survivorship plans for children. lenging to predict as the damage can be affected by many factors, including total radiation dose, fractionation schedule, treatment volume, age of the child, symmetry of the delivered dose over vertebrae, developmental status of the irradiated growth plates, and other treatments such as chemotherapy or surgery, as well as inherent factors

such as endocrine abnormalities and bone growth aberrations [associated with] tumor location.” The SIOPE working group’s recommendations include acceptable dose gradients for children of different age groups when dose fall-off or inhomogeneities cannot be avoided within vertebrae. “We recommended that between the ages of 0 years and around 6 years, partial irradiation of the spinal column should be limited to approximately 7 thoracic vertebrae, particularly for doses of more than 20 Gy, if it is possible to do so without compromising target volume coverage,” Dr Hoeben and colleagues reported.1 The available research base remains relatively immature. The SIOPE radiotherapy working group recommendations therefore represent a tentative framework guideline that “can be reevaluated and updated as more reliable data become available,” the investigators wrote.1 The SIOPE radiotherapy working group recommendations are limited

to radiotherapy treatment planning but can be used to inform survivorship plans for children treated for cancers. ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. REFERENCES 1. Hoeben BA, Carrie C, Timmermann B, et al. Management of vertebral radiotherapy dose in paediatric patients with cancer: consensus recommendations from the SIOPE radiotherapy working group. Lancet Oncology. 2019;20(3):e155-e166. 2. Jairam V, Roberts KB, Yu JB. Historical trends in the use of radiation therapy for pediatric cancers: 1973-2008. Int J Radiat Oncol Biol Phys. 2013;85(3):e151-e155. 3. Hogeboom C, Grosser S, Guthrie K, et al. Stature loss following treatment for Wilms tumor. Pediatr Blood Cancer. 2001;36(2):295-304. 4. Hudson MM, Ness KK, Gurney JG, et al. Clinical ascertainment of health outcomes among adults treated for childhood cancer. JAMA. 2013;309(22):2371-2381.

myCME Simpliﬁes Your CE Search Relevant courses automatically displayed based on your profession, specialties and topics of interest Extensive array of accredited CE activities in dozens of therapeutic areas

Personal dashboard of bookmarked, in progress and completed activities Resources and Trending features keep you updated with personalized medical news and information, along with rankings of the most popular CE activities

Your personalized myCME homepage will make it easier to ﬁnd relevant CE activities.

Simplify Your CE Search. Visit myCME.com Today

www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 27

COMMUNICATION CHALLENGES

Using Courage in Your Practice

Ann Brady, MSN, RN-BC, CHPN

It may be easier to say “be brave, use your courage” than it is to acknowledge there is a need to be brave.

an, Nan. Do you know what I did?” I was FaceTime chatting with my 6-year-old grandson, and he was telling me about the fieldtrip his class went on that day. He is always exuberant, always sharing his 6-year-old wisdom. “What did you do?” “I petted a snake.” “Oh, my. Weren’t you afraid?” “No.” He shrugged his shoulders. “I used my courage.” I love this line. It seems like a good philosophy for all of us. When I am hesitant to do something or uncomfortable about trying, I think of his words. Those times when I hesitate because I am afraid, in whatever form that may take: afraid I might not do it well, afraid doing it will anger someone, afraid because I’ve never done it before. Remembering that fear and courage are linked. The saying “out of the mouth of babes” is so true. Kids are matter-of-fact about things an adult would never admit to. They are brilliant

28 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

in their innocence. Somehow, as we get older and lose some of that innocence, we also let go of looking at things very simply. We make things more complex than they need to be, adding layers of difficulty to shore up the walls we erect. Oh, to be able to say very humbly and sincerely, “I used my courage.” But I also like the idea of how he said my courage, meaning his courage was there and available to use. All of us have had patients or families who challenged our practice. But layered onto the complexity of their care is our personal response. Perhaps it was uncomfortable because of a personality mismatch or an ethical dilemma. These are the situations in which we tell and retell the story, “I’ll never forget Mr X, he was in room 127 and …” We live with the “and …” part of the story, maybe with satisfaction over how we handled a difficult situation, or regret, or sometimes with a totally blunted response. I may even take that discomfort and project it to the patient: He was so difficult. The family just didn’t get it. The bottom line is something made us uncomfortable. Addressing that discomfort takes courage. I used my courage. What might that look like? It may be easier to say “be brave, use your courage” than it is to acknowledge there is a need to be brave. The idea of taking time to examine our response when we are expected to quickly move on to the next patient and their needs does not allow for reflection. Easier to push it down. After a while we almost forget the stress of it. Almost. This makes me think of our patients when we ask “how are you doing?” and they say “I’m fine.” Yet we look at them and know it isn’t true. It is easy to see that as a nurse, harder to see the emotional pain we may be masking from ourselves and others. I have heard nurses say, “It was really difficult.

But I’m okay, really I’m okay.” Sometimes the statement, “But I’m okay” is repeated so many times it becomes difficult to believe. DISCUSSION How do we find the courage to reassess our stressful interactions? As caregivers we may struggle with the idea that we might need care ourselves. If I admit a struggle maybe I am not as good a nurse as the one who just keeps going. I have had nurses tell me, “But everyone else seems to be doing so well,” and the admission that they are not makes them feel weak in their practice. But of course, we need to use our courage when considering our emotional response to patient situations. In particular, those situations where we find ourselves at a loss for what to do are an easy time to give in to fear. One red flag for me is when I find myself retelling the story of what happened again and again. As I hear myself repeat the words, I now have trained myself to say, “What is it about that situation that makes me need to repeat it? What am I struggling with in this instance?” Retraining our inner calculations is not easy. I may dismiss my own red flag. “It’s because I was tired that day,” or, “the family was so overwhelming, that’s all that it was.” But burnout does not happen suddenly. It happens slowly, over time, as we let distress seep into our practice and rob us of the passion that made us choose to be a nurse in the first place. We hear about the importance of self-care but don’t always hear how to practice it in anything but general terms. Get a good night’s sleep; exercise regularly; eat right. These are all things we are supposed to do anyway. What else does self-care look like as a nurse? Does it extend to our self within a group or unit? Most of us practice within a larger group, which is essentially a larger self. How do we ensure self-care extended beyond self? It means care of the others we work with. So what does that look like? It involves many of the skills we use as nurses: good assessment and reassessment. What do we see? What questions do we ask?

Here are practical, brave suggestions for selfcare of our individual selves and group selves: Take the time to debrief, especially after unusual and complicated situations; for example, an unexpected code, a mismatch between treatment and expectations, or barriers in providing the best care. Write down your feelings about the situation. Adopt a practice of self-care as a unit, notice the coworker who may be struggling and ask ourselves, “Is this the appropriate reaction/is it the reaction I expect to see in others?” It would be okay — and not a betrayal of trust — to let the supervisor know that you or others are having a difficult time coping with a recent situation. Can we formally debrief as a unit? Who sets that up and what does it look like? Advocate for ourselves and each other, not just for our patients and families. Brené Brown, PhD, MSW, is a research professor at the University of Houston who studies courage, vulnerability, shame, and empathy. A quote from her explains what courage looks like, “Asking for what you need. Speaking your truth. Owning your story. Setting boundaries. Reaching out for support.”1 Nurses by definition are care givers. We give care away. Sometimes it seems that in the process we may fail to save some of that care for ourselves. The flip side of courage is vulnerability. What happens if I use my courage to reassess my care of a patient and listen to my inner voice? Doing so makes me vulnerable but yet opens me up to support. What if I used my courage to acknowledge my work distress and to ask for support? How much healthier of a nurse might I become? How much better of a nurse might I become for my practice and for my patients? ■

What happens if I use my courage to reassess my care of a patient and listen to my inner voice?

Ann Brady is a symptom management care coordinator at a cancer center in Pasadena, California. REFERENCE 1. Brown B. The Call to Courage [streaming video]. Los Gatos, CA: Netflix; April 2019.

www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 29

Managing Fatigue and Other Adverse Effects of Breast Cancer With Self-Acupressure Bette Weinstein Kaplan

lthough performing acupressure on yourself sounds a little strange, self-acupressure is an effective modality for cancer patients coping with fatigue, pain, depression, and other symptoms of their disease, according to Suzanna Maria Zick, ND, MPH, research associate professor of family medicine and nutritional sciences and co-director of integrative family medicine at the University of Michigan. She and her colleagues had been looking for a self-care technique for their patients with breast cancer when they decided to try acupressure. A component of traditional Chinese medicine, acupressure utilizes pressure applied with the thumb, finger, or even a device, to points located throughout the body.1 The investigators had considered using acupuncture, which is known to yield encouraging results, but encountered barriers: a high dose is often necessary for patients 65 years old and older. In acupuncture, dosing translates to frequency of treatments, and older people tend to have the most difficulty coming to the office more than once or twice a week, so more frequent visits are more difficult. Also, acupuncture is not covered by insurance in Michigan. The state does not have any licensed acupuncturists, and in fact, it does not have many acupuncture practitioners at all. After considering the barriers to acupuncture treatment, Dr Zick and her

group decided that the ideal option would be to teach their patients to perform acupressure on themselves. Acupressure is a modality patients can perform wherever they are, and they can increase the dose to as often as every day, if need be. The treatment costs nothing; it just takes a little time. “Teaching selfcare techniques can be quite powerful,” Dr Zick told Oncology Nurse Advisor. INTRODUCING THE TECHNIQUE

Acupressure uses the same acupoints as acupuncture, and stimulating the points can bring about an improvement in illness and symptoms. This is one treatment women could do entirely by themselves. The women were intrigued at the concepts of self-care and acupressure. Patients ranged in age from 30 to 89. Staff members, referred to as acupressure educators, showed the women where the 9 acupoints were on their bodies and how to stimulate each point in a circular motion for a full 3 minutes. Starting with the points on the head, they performed the technique at each point down to the toes from right to left. Each woman was given a handout that illustrated where the points were, reminded them how long to press on each point, and reinforced all the things they had heard in the session. Some patients had arthritis in their hand and others had various types of resting tremors, but these conditions did

30 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

not affect their acupressure practice. Nor was it affected by disease stage at initial diagnosis, menopausal status, or type of treatment. Location and time of day were highly variable. Some patients performed acupressure at work, others did it at home when they first woke up or just before they went to bed, and some performed it during their lunch break at work. A FOCUS ON FATIGUE, EASE OF COMMON SYMPTOMS

Although the investigators specifically targeted fatigue, Dr Zick told Oncology Nurse Advisor they were also concerned about sleep quality, depressive symptoms, anxiety, and chronic pain. These symptoms are more common in breast cancer survivors. The team knew there was overlap with all the symptoms; a woman rarely has fatigue by itself. She will have fatigue, or fatigue and depression. “Some unlucky women have all of the symptoms. So we said that for the study everybody had to be experiencing fatigue, but we measured all the other symptoms as well to see whether or not they were also impacted,” said Dr Zick. Clearly, what some of the pain patients felt was chemotherapy-induced neuropathy, but the researchers did not ask specifically whether the patient had neuropathic pain. Their research used the Brief Pain Inventory, which asks about having any type of pain anywhere Continued on page 32

FROM

he word meditation has become ubiquitous in American culture since Johnny Carson popularized it on everyone’s favorite late night show in the 1960s, yet many people still don’t know what it is, especially those in marginalized communities. Similarly, people who are religious may fear underlying proselytizing. When people are confronted with a diagnosis of cancer, shock and fear often open them to new coping strategies such as integrative medicine (IM). To that end, nurses and social workers are in ideal positions to introduce meditation practice to patients and caregivers as a tool to address stress. Using a 3-step introduction helps when talking about meditation, especially with those who are new to the concept of IM. First, educate the patient: meditation is a practice to help quiet the mind and focus attention. This simplifies the practice and immediately identifies its benefits. The need for quieting the mind and focusing attention is more pronounced during a crisis such as receiving a cancer diagnosis, when both peace and focus are challenged on multiple fronts. Second, provide analogies that can normalize the technique: recitative prayer, walks in nature, soft music, silence, a cup of tea; and, believe it or not, running, fishing, and other individualized sports, as well. These steps paint a familiar picture patients can relate to and normalize an understanding of how they might already be engaging in some form of meditation. After 45 years of practicing meditation and 20 years teaching it, I am still surprised at how that simple beginning,

Easy Meditation Practices for Patients and Caregivers Richard Dickens, LCSW-R

even for experienced meditators, creates or reinforces a foundation for the practice. However, the third step is the most crucial: breath. BREATH TECHNIQUES In a crisis of cancer, like all crises, our fight-or-flight response kicks in and can

lead us into a state of chronic hyperarousal. Introducing a 3-breath exercise to bring one back to the parasympathetic nervous system is crucial, and even by itself, managing breath can produce enormous benefit when fear begins to take over. Oncology nurses know the importance of healthy breathing better than anyone. Grounding people in diaphragmatic breathing can be fun, provide a point of focus, and offer a simple way to calm the mind and body. Here are two common breathing exercises. Place one hand on the chest and the other on the abdomen, with thumb on the navel; stand profile to a mirror and watch your chest and stomach expand and contract with each breath. Standing, put your hands on the bottom of the ribcage and feel the expansion when you breathe in, especially in the back. Breathing exercises are not unique to meditation — other psychological theories, such as cognitive behavioral therapy (CBT), also incorporate the importance of breath. MEDITATION TECHNIQUES Teaching new techniques without a foundation and without understandable goals is bound to lead to failure, disinterest, or self-recrimination for not doing it right, thereby increasing anxiety. Many meditation practices are intertwined with Hindu and Buddhist teachings taught by gurus; however, those taught within IM centers are secular and presented as tools to achieve peace and maintain focus in the midst of every day stressors. Transcendental meditation (TM) and mindfulness are perhaps the 2 most common meditation practices in the

Grounding people in diaphragmatic breathing can be fun and offers a simple way to calm the mind and body. www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 31

FROM West, with many years of research supporting them. TM, sometimes referred to as a one-point meditation, uses a mantra — a single-syllable sound — as the point of focus to quiet the mind, with the goal of transcending thought to no thought. People unable to go through the formal teaching can use this technique by incorporating an affirming one-syllable word such as love, hope, joy, health, or peace, thereby adding an affirmation to help quiet the mind. TM typically is a 20-minute sit twice a day. More commonly practiced in America is mindfulness, sometimes referred to as a 2-point meditation: breath as the point of focus and nonjudgmental awareness when you notice the mind has wandered. The truth is that thoughts start well before we are consciously aware of them. In times of crisis, those thoughts are often negative, spiraling into anxiety and/or depression. The metaphor monkey mind is often used to describe jumbled thoughts. Just as monkeys jump indiscriminately from tree to tree, our

The Total Patient Continued from page 30

in the body: How severe is your pain? Where in your body is it? How long have you had it? When is it the worst? Some women indicated having neuropathic pain by pointing to the hands and feet, common sites for neuropathic pain, when asked to show on a body map where their pain was. But patients in the study experienced pain in a variety of locations, including the lower back, knee, head, or neck. Dr Zick reported that interest in all different types of pain felt by survivors is increased. For example, even in cases of knee osteoarthritis, breast cancer survivors have more pain than one would expect. This could be because the more

thoughts jump indiscriminately from idea to idea. The wandering mind is often triggered by somatic sensations in our bodies or psychic thoughts in our brains. A sensory sensation gets processed in the mind creating an emotion. Likewise, a psychic thought gets held in our bodies creating tension.

Most important is to leave people feeling that doing it just once can help. As a result, in both cases during crisis, negative thoughts or painful feelings can double one’s suffering. A 3-breath exercise in one of the above positions (breathe in filling the lower lungs, slight pause, then exhale, with a long pause after 3 breaths) almost always calms the mind and changes the tone and energy of a crisis moment.

centralized pain of breast cancer causes patients to be more sensitive to painful signals from their periphery. HELPFUL TOOLS AcuWand Many women use pencil eras-

ers rather than their fingers or thumb to stimulate their acupoints. In focus groups, they said that having a device to do that would be easy on their hands and also enable them to apply an accurate amount of pressure. The result was the AcuWand. The small stick device makes it easy to apply pressure and vibrates if the patient applies too much pressure. MeTime Acupressure The Michigan team has also developed a mobile phone app that provides detailed video and schematic support to help anyone learn where the acupoints are and how to

32 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

These 3 simple steps establish the foundation of meditation and can be presented in a common area or private place. If it resonates, patients can continue beyond 3 breaths and be referred for additional grounding in the practice or to CancerCare’s free meditation app with experienced teachers and hours of calming music. Perhaps most important is to leave people with the feeling that doing it just once can help, and avoid leaving them with the feeling that this has to be a disciplined practice to reap the benefits. People confronting cancer are already feeling that they have to do everything right. Letting patients know that they can use this tool as they wish, and feel good about doing it when they do, can be the reward in and of itself. ■ Richard Dickens is director of Client Advocacy at CancerCare. For a list of suggested readings on meditation, go to the online version of this article. Use this link: https://bit.ly/FromCancerCare0519.

press on them. The app is available for iOS and Android; proceeds go toward future research projects in the department at the University of Michigan. Focus group feedback Positive comments from focus group participants include: “The acupressure worked really well and I was happy to participate.” “It was extremely helpful.” “I found I was sleeping better and I had more energy. This is what it’s like to feel good!” ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Zick SM, Sen A, Hassett AL, et al. Impact of self-acupressure on co-occurring symptoms in cancer survivors. JNCI Cancer Spectr. 2018;2(4):pky064.

THE PATIENT’S VOICE

Help on a Hard Road Lee Hillstrom

irst there were tests, then a biopsy, and finally a diagnosis: “You have prostate cancer.” How could anyone plan for this moment? Questions that immediately came to mind were what stage am I, what are the chances of whatever path I take working, and what will the side effects be? “Cured” was a word I’d read men with prostate cancer will never hear. I was told I was not the typical prostate cancer patient as I was too young, in good health, ate well, didn’t smoke, and didn’t drink alcohol. I thought to myself, what could I have possibly done differently? How about not having a brother with the disease a year earlier? I underwent a robotic prostatectomy in 2009. Five years later my cancer was back with external radiation treatments being my best option, but even that had only a 50% chance of working. I wondered how this could happen, because after my surgery, I had only a 15% chance of my cancer coming back in the next 10 years. Two doctors told me the combination of surgery and radiation would make me impotent and 1 optimistic doctor said that was just a possibility. AN INTRODUCTION TO NAVIGATION

I was waiting to see my radiation oncologist for the first time when Ms S walked in and introduced herself as my cancer navigator. After a few words about contacting her with any questions, our meeting was cut short by the arrival of my radiation oncologist. I had never heard of someone called a navigator and wouldn’t understand how helpful she could be until much later. Men with prostate cancer face so many embarrassing experiences. For me, the embarrassing moments came after surgery when a female nurse

checked on different areas in my genital region every hour. During radiation, it was the daily lowering of my pants so the female radiation therapists could line up the tattoos on each hip and my pubic area. Before my treatments started, I couldn’t sleep through the night, whereas during my treatment days that problem disappeared. As the end of treatment came into sight, however, I started to become fearful again and wondered if Ms S could help in some way, so I asked if I could talk with her. Ms S met with me, heard my concerns, and scheduled a follow-up appointment so that we could talk longer. The next time we met, she listened while I talked about many things, including having to wait 3 months for my first PSA test to see if my radiation treatments worked. If they didn’t work, I would need to start hormone therapy — often referred to as chemical castration. Hot flashes, weight gain, loss of muscle mass, the ability to have an erection, or even have thoughts of sex, along with other side effects, were my biggest concerns. Ms S was different from many I have met in the medical field in that she expressed concern on her face as we spoke. After our second meeting, she scheduled yet another follow-up appointment. In the meantime, I wrote thank you letters to those who had treated me and even met with the chief operating officer of the medical center to let her know how much I appreciated the great care the staff had given me. All of this was happening just before Christmas, when I received a message from Ms S. She wrote: “Lee, I don’t think that you can fully realize how much your praise of the staff and experience means to all of us. We frequently get treats from patients and are sometimes thanked in person,

www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 33

THE PATIENT’S VOICE but it really is so meaningful that you bring your experience forward on a larger level. It’s a rewarding message to hear at a time that can often be stressful for many of us! So thank you. It goes to show how one person can make a very big impact on the lives of others.” When Ms S and I met again it was obvious to her that I needed help she wasn’t qualified to provide, so she asked if I would be willing to talk with a cancer counselor. If yes, she would set up an appointment for me. I agreed to meet with Ms K. I learned later that few men take advantage of this support resource and that Ms K’s title is “cancer counselor” because even fewer patients would agree to see a “therapist.” MY SUPPORT STRUCTURE BROADENS I had kept a journal of my days during radiation therapy. It detailed the interactions between those treating me and my conversations with other men waiting to be treated. I wrote about the minor things that sometimes allowed me the little smile that I so craved, and the side effects that led to some extremely embarrassing moments, and my fear that more might be coming. Last, I jotted down some simple suggestions on what would have helped make these weeks of treatments easier — such as having my navigator check in on me, although the feeling of being heard by the counselor was nice. As I am now a caregiver for my wife, who recently finished radiation treatments for breast cancer, I know first-hand that patient interactions with the navigator have greatly increased at this cancer center. I quickly became comfortable talking with Ms K, and several times I told her stories that had us both laughing out loud. A welcome feeling as I was desperate to get back to enjoying my life again. Ms K was also skilled at asking the tough questions, the ones that often had me looking anywhere but in her eyes, and at times, reaching for a Kleenex. My cancer journey has caused me to become much more emotional, and showing those emotions challenges the strong male image I feel the need to live up to. Doubt was a problem for me after my diagnosis and treatment. I often second-guessed things I had done in the past, questioning how they may have contributed to my cancer diagnosis. In fact, I continue to wonder about things I have done or am doing. I’m not sure who said “Cancer may leave your body, but it will never leave your mind,” but that is an accurate description of my cancer journey. INVISIBLE SIDE EFFECTS With the help of Ms K, I learned breathing exercises that can be very helpful. When I had difficulty sleeping through the night, diaphragmatic breathing along with visualization

was helpful. Every day I perform my 4, 7, 8 (inhale, hold, and exhale) breathing exercise whenever I need to take a minute to relieve the stress in life or at work. Meditating for a few minutes each morning while listening to a free phone app called Insight Timer was a great help. The effects of cancer can bring back painful memories from the past. In my case, after learning to trust Ms K, I left her a letter about a trauma I experienced when I was 10 years old. I had never shared this information with anyone. But every word said and action taken had come back to me, and I now felt for the first time that I needed to finally talk about it. Ms K explained that my feelings of embarrassment at dropping my pants in front of the female radiation therapists probably brought back that memory. Cancer affects you physically in many ways, but there may come a day when the past, the present, and the future all collide and challenge you to survive your thoughts. Financial problems, family issues, no longer being the person you were, and shame can dominate your thoughts. To better understand how those feelings can affect someone and recognize when help is needed, I have twice taken a QPR (Question, Persuade, and Refer) course. At a support group meeting, I heard a urologist say that prostate cancer turns men into girls. It wasn’t meant to be an insult to women, but the harsh reality is that you will experience many things that are a normal part of life for a woman. If you are honest with a woman who asks, “How you are doing?” you can expect many of them to say, “Now you know what we go through.” Recently, I even heard that from a nurse. Sharing my thoughts and experiences in an open and honest way can be challenging for me; feeling ridiculed after doing so makes me less likely to share further. Because prostate cancer mostly affects men in their 50s and older, I suspect that many patients grew up watching their fathers be the family breadwinner, most likely never showing weakness, and able to handle any situation without help. I believe this is an important thing to keep in mind when discussing diagnosis and treatment with patients. Ms K suggested 2 books that could help me better understand the shame and feelings of imperfection cancer can bring: The Gifts of Imperfection (Hazelden; 2010) and Daring Greatly (Avery; 2012); both by Brené Brown, PhD, LMSW. Reading these books was helpful. Dr Brown talks about interviews with many adult males who feel shame for no longer being the person they once were. Men’s cancer journeys have found many of us on our backs with our legs up in stirrups, wearing pads, practicing Kegel exercises, and dealing with urinary and fecal incontinence. We may have to learn to manage erectile dysfunction with

34 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

a pill, a pump, or penile injections. Even after all of that, some patients are not able to replace the capabilities they lost and find themselves seeking alternative methods, such as watching porn. These topics can be very challenging and embarrassing to talk about — but they must be discussed by both the patient and their healthcare team. HELPING OTHERS HELPS ME My journal and our meetings led Ms S and Ms K to ask me to start and lead a much-needed prostate cancer support group in my community. However, Ms S warned me to not rush into this. She knew I needed more time to recover before taking on the problems of others. She found an online group by the name of Us TOO International. Eventually, I became affiliated with them and started a local chapter. I learned a great deal about handling challenges from Ms K and Ms S and am now doing my best to earn the trust of the members in my group. When I meet with couples who just received a prostate cancer diagnosis and have many questions about what is ahead for them, it is interesting to hear what each hopes for or fears. The wife/partner is most worried about her husband surviving and then about the possibility of depression challenging him and affecting their relationship; whereas it is probably no surprise that the man’s fears focus on incontinence and erectile dysfunction. Couples really appreciate being able to talk with someone who has experienced the treatment options they have before them and is willing to openly and honestly answer

any questions relating to those past experiences as well as current side effects. I also attended support group meetings at a cancer center where patients with all types of cancer were welcome. It was an interesting experience because I was the only male survivor attending each month. They are all part of what I now consider my cancer family. Last year I was awarded the “Healthcare Volunteer of the Year Award” for the area of the state I live in. There were 600 people at the banquet that evening celebrating those who won in several categories. In my speech, I quoted Edward Everett Hale: “I am only one, but I am one, I cannot do everything, but I can do something. And because I cannot do everything, I will not refuse to do the something that I can do.” Cancer has changed the most important parts of my life. Every morning I now give thanks for another day and pray I will do my best to make it a good one. Enjoying special moments with my family is a privilege I appreciate better. I believe that all navigators must have had an influence in their life to lead them into this line of work. For me, the rewarding work I now find myself doing for patients would never have happened without Ms S, my cancer navigator, being the most caring and compassionate person I have ever met — who gave great hugs, when needed — and my cancer counselor/therapist, awesome Ms K, teaching me so much about what is really important in my life. ■ Lee Hillstrom is a cancer survivor, caregiver, and advocate.

Download the

FREE APP

for Real-time Information Across All Specialties

Never miss an update when you enable push notifications.

Access Oncology News From Your Favorite Mobile Device

CancerTherapyAdvisor.com/app

www.OncologyNurseAdvisor.com • MAY/JUNE 2019 • ONCOLOGY NURSE ADVISOR 35

ASK A PHARMACIST

medications that are dosed more closely together, such as aspirin or penicillin, this must be done each time the medication is resumed after a break in therapy. Some of our patients are concerned about changing to generic chemotherapy drugs. Are these as effective as the brand name drugs? — Name withheld on request

Graduated Doses; Efficacy of Generics How often should a patient be desensitized to medications? — Name withheld on request

Desensitization refers to the process of starting a medication in very low amounts and gradually increasing the dose. Patients may be hospitalized and also receive premedications to reduce the risk of a severe reaction. Desensitization may be done for patients at risk for significant allergic reactions to medications but no acceptable alternative is available; for example penicillin or, for chemotherapy, platinum agents. Administering the medication in this manner can help prevent the allergic reaction from occurring. Desensitization must be performed each time the patient receives the medication. For a medication dosed with breaks in treatment, such as oxaliplatin, this must be done with each dose. For

Generic medications contain the same active ingredient as the respective brand name products. Stringent testing is required to prove that the generic drug is absorbed into the systemic circulation to the same extent and at the same rate as the brand name drug. They must also meet the same standards for purity, quality, and strength as the brand name product. Generic medications that meet these standards are listed in the Orange Book. Generic chemotherapy drugs must also meet the same strict standards. Generic medications generally cost less than brand name products as costs to develop the drug are lower and competition between multiple manufacturers of the same product is greater. These reduced costs frequently benefit patients in the form of reduced copays for generic drugs compared with brand name drugs. What advice should I give patients and family members regarding

disposal of old medications and/or narcotic pain medications?

Due to ongoing concerns regarding handling of opioids and other controlled medicines, the editors decided to update information from a previous column in which Dr Thompson discussed recommendations for disposing of unused medicines. The best method of drug disposal is through a take-back program. Patients and families can find out about these events by contacting their local law enforcement officials to find a location near them or check with the Drug Enforcement Administration (DEA) to find a DEA-authorized collector in their community (www.deadiversion. usdoj.gov/drug_disposal/takeback/). If there are no take-back programs in the patient’s community, patients should check the label or patient information leaflet for recommended disposal methods. Patients can also check “Disposal of Unused Medicines: What You Should Know,” a section on the US Food and Drug Administration website that offers up-to-date information on drug takeback options, how to properly dispose of medicines, answers to frequently asked questions, and various printerfriendly education materials to hand out to patients. For these and more resources, go to www.fda.gov/consumers/consumer -updates/where-and-how-dispose -unused-medicines. ■

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

36 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2019 • www.OncologyNurseAdvisor.com

Philadelphia, Pennsylvania June 13-15, 2019

Review highlights and expert perspectives Browse news and speaker-authored session summaries from the Summit. Topics include: • The Role of Navigation in a Changing Health Care Environment

KEY TAKEAWAYS

AVAILABLE ONLINE

• Addressing the Financial Concerns of Patients With Cancer • The Role of the Nurse Navigator in Disaster Planning • PARP Inhibitors: Their Role Across Tumor Types

OncologyNurseAdvisor.com/Summit19