ONA September/October 2018 by Haymarket Media

September/October 2018

www.OncologyNurseAdvisor.com A F O R U M F O R P H YS I C I A N A S S I S TA N T S

FEATURE

PATIENT NAVIGATION Fitness Wearables Are Finding a Place in Oncology Care

ASK THE EXPERTS

A Case Study on PV From Diagnosis Through Optimal Management

COMMUNICATION CHALLENGES

Keep/Start/Stop Analysis

ISSUES IN CANCER SURVIVORSHIP

Postmastectomy Satisfaction, QOL Depend on Breast Reconstruction Choice

RADIATION & YOUR PATIENT

Radiotherapy Abscopal Effects: A Boost for Immune Therapy?

THE TOTAL PATIENT

Hypnosis in Men With Prostate Cancer vs Women With Breast Cancer

Integration of Oral Care by a Dentist Into Cancer Surgery Treatment Plans Debridement of plaque harboring pneumoniacausing bacteria can reduce the risk of postoperative pulmonary adverse events.

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Oncology Nurse Advisor (ISSN 2154-350X), September/October 2018, Volume 9, Number 5. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. 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.

EDITORIAL BOARD Eucharia Borden, MSW, LCSW, OSW-C Lankenau Medical Center Wynnewood, Pennsylvania Ann J. Brady, MSN, RN-BC Huntington Cancer Center Pasadena, California Jiajoyce R. Conway, DNP, CRNP, AOCNP Cancer Care Associates of York York, Pennsylvania Marianne Davies, DNP, ACNP, AOCNP Smilow Cancer Center @ Yale New Haven New Haven, Connecticut Frank dela Rama, RN, MS, AOCNS Palo Alto Medical Foundation Palo Alto, California Donald R. Fleming, MD Cancer Care Center, Davis Memorial Hospital Elkins, West Virginia Leah A. Scaramuzzo, MSN, RN-BC, AOCN Kalispell Regional Healthcare Kalispell, Montana Lisa A. Thompson, PharmD, BCOP Kaiser Permanente Colorado Rosemarie A. Tucci, RN, MSN, AOCN Lankenau Hospital Wynnewood, Pennsylvania Kara M. L. Yannotti, MMH, BSN, RN, CCRP John Theurer Cancer Center at Hackensack University Medical Center Hackensack, New Jersey

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CONTENTS 5

IN THE NEWS • Cervical Cancer Screening Guidelines Updated • Real World Results Do Not Mirror Clinical Study Outcomes in Multiple Myeloma • PVX-410 Vaccine Delays Disease Progression of SMM to Symptomatic MM • Cytoreductive Therapy Improves Outcomes in PV … and more

ONCOLOGY NURSE ADVISOR FORUM • Handling Chemotherapy Premedications • Antioxidant Interaction With Cancer Therapy

NAVIGATOR NOTES How Accurate Is the Information Cancer Patients Find Online?

September/October 2018

Megan Garlapow, PhD

FEATURES Including Oral Care in Cancer Care Plans Improves Outcomes Megan Garlapow, PhD

Fitness Wearables Are Finding a Place in Oncology Care Bette Weinstein Kaplan

How Effective Are Skin Cancer Screening Programs? Bryant Furlow

ASK THE EXPERTS A Case Study on PV From Diagnosis Through Optimal Management Lindsey Lyle, MS, PA-C

JOURNAL REVIEW Choosing an Effective Lung Cancer Screening Model John Schieszer, MA

Continues on page 4

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JOURNAL REVIEW

New Formulations Improve Management of ChemotherapyInduced Nausea and Vomiting

CONTENTS

September/October 2018

In a recent report, researchers evaluate the efficacy of newer 5HT3-RAs for the prevention of CINV in patients with cancer receiving moderately or highly emetogenic chemotherapy. John Schieszer, MA

JOURNAL REVIEW Chemotherapy Still Beneficial With Midrange 21-Gene RS John Schieszer, MA

STAT CONSULT Talimogene Laherparepvec (Imlygic) RADIATION & YOUR PATIENT RT Abscopal Effects: A Boost for Immune Therapy? Bryant Furlow

COMMUNICATION CHALLENGES Keep/Start/Stop Analysis Ann J. Brady, MSN, RN-BC

ISSUES IN CANCER SURVIVORSHIP Postmastectomy Satisfaction, QOL Depend on Choice of Breast Reconstruction Bette Weinstein Kaplan

THE TOTAL PATIENT Hypnosis: A Comparison of the Efficacy of an Intervention Across Patient Populations Bette Weinstein Kaplan

FROM CANCERCARE Defining Hope, Gratitude, and Spirituality for Patients With Cancer

FACT SHEETS

Paget Disease of the Breast

Review of Paget disease of the breast symptoms, diagnosis, and treatments. Oral Contraceptives and Cancer Risk

Review of the possible cancer risks and also possible protective benefits associated with the use of oral contraceptives. PUBLISHERS’ ALLIANCE: DOVE PRESS

Current Status and Dilemma of Secondline Treatment in Advanced Pancreatic Cancer: Is There a Silver Lining?

Although relapse is common, many patients are good candidates for secondline therapy. This report reviews second-line therapies for advanced pancreatic cancer. OncoTargets and Therapy

Long-term Survival Effect of the Interval Between Mastectomy and Radiotherapy in Locally Advanced Breast Cancer

Retrospective study investigates the effect of radiotherapy on long-term survival in patients who underwent mastectomy for breast cancer at various time intervals. Cancer Management and Research

Sonia Pacheco, MSW, LSW, LCSW

ASK A PHARMACIST High-Dose Flu Vaccine in Elderly Receiving Chemotherapy Lisa A. Thompson, PharmD, BCOP

ON THE

WEB

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IN THE NEWS Cervical Cancer Screening Guidelines Updated The US Preventive Services Task Force (USPSTF) updated its screening recommendations for cervical cancer. This marks the first Task Force recommendation update since 2012. Although the total number of deaths attributed to cervical cancer have decreased in the past 2 decades from 2.8 deaths per 100,000 women down to 2.3 per 100,000, an estimated 13,240 new cases and 4170 deaths will occur in 2018. Evidence suggests that most cases of cervical cancer occur among women who have not been appropriately screened; improved recommendations and strategies may continue to reduce mortality associated with cervical cancer. The USPSTF reviewed evidence from trials and cohort studies in high-resource countries assessing the effectiveness of high-risk human papillomavirus (hrHPV) testing or hrHPV testing plus cytology (co-testing) compared with cytology alone. Harms of hrHPV alone and co-testing is that these 2 tests would subject women to more tests and procedures. Therefore, the USPSTF made the following Grade A recommendations (recommended service with high certainty of net benefit): For women aged 21 to 29 years, screening with cytology alone every 3 years outweigh the harms. For women aged 30 to 65 years, screening with cytology alone every 3 years, with hrHPV testing alone every 5 years, or with co-testing every 5 years outweighs the harms. They also added that screening women 65 years and older who had undergone previous adequate screening, women younger than 21 years, and women who have undergone a hysterectomy with cervix removal for indications other than high-grade precancerous lesions or cervical cancer, does not confer any significant benefit (Grade D recommendation). The major change in the updated vs the 2012 recommendations is that hrHPV testing alone is now recommended as an alternative to screening every 3 years with cytology alone for women aged 30 to 65 years.

Financial Toxicity Discussions an Unmet Need for Breast Cancer Patients Cancer often leads to employment disruptions and financial difficulty among patients with the disease, and evidence suggests that financial burden is associated with overall distress, lower health-related quality of life, and satisfaction with cancer care. Whether physician attention and interactions with patients properly address this issue was assessed in this study. Researchers assessed questionnaire responses of 2502 patients with early-stage breast cancer and their healthcare providers; 370 surgeons, 306 medical oncologists, and 169 radiation oncologists responded to surveys. Patient and physician attitudes and communication of financial toxicity,

patient desires for clinician engagement, as well as patient unmet needs pertaining to financial toxicity were evaluated. Results showed that 50.9%, 15.6%, and 43.2% of medical oncologists, surgeons, and radiation oncologists, respectively, reported that someone in their practice frequently or always discusses financial toxicity with patients. Of the 945 women who worried about finances, however, 72.8% (679) reported that their physicians and staff did not help, and of 523 women who wanted to talk to their physicians about the impact of breast cancer on employment or finances, 55.4% (283) reported that such conversations never occurred. Read more at http://bit.ly/2QVZx1C. In the News continues on page 6

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IN THE NEWS

Previous studies have demonstrated that patients with type 2 diabetes treated with metformin have a lower incidence of various cancers and improved long-term oncologic outcomes compared with other therapies. The impact of metformin on the incidence and prognosis of bladder cancer was examined in this review and meta-analysis. Researchers assessed the outcomes of 9 retrospective cohort studies encompassing 1,270,179 patients. Eligible studies evaluated the association between metformin use and bladder cancer incidence and various prognostic measures, such as progression-free survival (PFS) and overall survival (OS). Five studies involving 1,269,642 patient lives demonstrated that metformin use does not decrease the risk of bladder cancer. A subgroup analysis based on ethnicity showed that metformin was significantly associated with decreased risk among Asian patients, but not among non-Asian patients. Four studies with a total of 537 patients showed that metformin intake significantly improved recurrence-free survival, progression-free survival, and cancer-specific survival. No significant prolongations of OS were observed. Read more at http://bit.ly/2OQ5ITg.

Do Sunless Tanners Have Fewer Skin Cancer Risk Behaviors? With the incidence of melanoma and nonmelanoma skin cancers on the rise in the United States, a recommended intervention to reduce preventable risk factors, such as UV tanning, is needed. Sunless tanning is considered to be a safe alternative, but in Likelihood of risky this cross-sectional study, researchbehaviors is mixed. ers assessed how it affects other skin cancer risk behaviors among those who use the practice. Data from the National Health Interview Survey were accessed to review the outcomes and behaviors of 27,353 survey participants. The survey assessed patient demographics and risk-affecting behavior, such as indoor tanning, skin cancer screening, sunburn, and sun protective behaviors. Overall, 6.4% of survey participants reported using sunless tanning in the past year; 4.5% used sunless or fake tanning products, 0.8% used spray-on mist tans, and 1.1% used both. Factors associated with sunless tanning were college

educated, non-Hispanic white, female, living in the Western United States, reporting higher sun sensitivity, and having a family history of skin cancer. Although sunless tanners were more likely to have had a full-body skin examination and use sunscreen, they were also more likely to have a recent sunburn and have indoor tanned, and less likely to seek shade or to wear long pants or sleeves when outdoors. Read more at http://bit.ly/2QVvHu4.

Lorazepam Did Not Improve CINV in Pediatric ALL CINV is among one of the most distressing adverse effects for patients receiving chemotherapy, and occurs commonly despite the large number of medications recommended for its prevention and management. Benzodiazepines, such as lorazepam, have been proposed as potential antiemetic agents. This retrospective chart review assessed its effectiveness in children. Researchers assessed the outcomes of 71 children with newly diagnosed ALL who were treated with granisetron alone or with lorazepam. Study patients received a total of 164 chemotherapy cycles, including treatment with vincristine, anthracyclines, and systemic steroids. Overall, nausea occurred in 72% (51) of patients and during 57% (93) of the chemotherapy cycles. Vomiting was observed in 66% (47) of patients and occurred in 48% (79) of chemotherapy cycles. No significant differences were observed in the incidence of nausea (P =.31) or vomiting (P =.98) among patients treated with granisetron plus lorazepam or granisetron alone. Read more at http://bit.ly/2N0Ec3F.

Mortality Rates for Lung Cancer Likely to Surpass Breast Cancer Among Women by 2030 Although incidence of breast cancer is higher than lung cancer, lung cancer has a worse prognosis and is a leading cause of cancer death. Improved screening and preventive practices have improved breast cancer mortality significantly, but trends in breast and lung cancer mortality require further study. In this study, researchers assessed cancer mortality data from the World Health Organization (WHO) database to

6 ONCOLOGY NURSE ADVISOR â&#x20AC;˘ SEPTEMBER/OCTOBER 2018 â&#x20AC;˘ www.OncologyNurseAdvisor.com

ÂŠ CSABA TOTH / GETTY IMAGES

Survival Outcomes in Bladder Cancer Improved in Metformin Users

project lung and breast cancer mortality in 52 countries until 2030. Age-standardized mortality rates (ASMR) — calculated per 100,000 — were reported for each country for 2015, 2020, 2025, and 2030. Results showed that median ASMR for lung cancer is projected to increase from 11.2 to 16.0, an increase of more than 40%, between 2015 and 2030; median ASMR for breast cancer, however, is projected to decrease from 16.1 to 14.7. The ASMRs for breast cancer and lung cancer are projected to decrease in 36 countries and 15 countries, respectively, in this time period. Further analysis revealed that the ASMR for lung cancer in half of the countries in the study and in almost 75% of countries considered high-income had exceeded or is projected to exceed the ASMR of breast cancer by 2030. “Being that low dose computer tomography implementation is still a matter of debate and with breast cancer mortality decreasing, prevention efforts should focus on smoking avoidance and cessation,” concluded the authors. Read more at http://bit.ly/2QUReD2.

Propolis Mouthwash Treatment Effectively Eases Severe Oral Mucositis Oral mucositis is one of the most common adverse events (AEs) of chemotherapy and radiotherapy for head and neck cancer, and severely affects quality of life and economic burden for patients with cancer. Evidence from previous studies that assessed Dose: 5-15 mL, 2 to the effect of propolis mouthwash was 3×/d for 7-180 days conflicting. In this systematic review, researchers assessed the outcomes of 5 randomized control trials that included 209 patients undergoing chemotherapy or radiotherapy. A total of 106 patients were assigned to the control arm, and 103 patients were treated with propolis mouthwash 5-15 mL, 2 to 3 times a day for 7 to 180 days. Results showed that patients in the intervention group who received propolis had a significantly lower risk for severe oral mucositis compared with patients in the control group. No serious AEs associated with the treatment of cancer therapy-induced oral mucositis were reported. Propolis mouthwash was found to be safe, effective, and well-tolerated. Read more at http://bit.ly/2DsPQF7.

Real World Results Do Not Mirror Clinical Study Outcomes in Multiple Myeloma Although the treatment of multiple myeloma has advanced in recent years, new treatment modalities have largely been evaluated in prospective clinical studies with strict inclusion criteria. How much these results translate to real world practice requires further investigation. In this prospective TLN cohort study, researchers assessed the outcomes of 3795 patients with hematologic malignancies after first- or second-line therapy; 285 nontransplant patients received systemic treatment for multiple myeloma. Trial ineligibility criteria included heart/renal failure, liver/ renal diseases, polyneuropathy, and HIV-positive status; the remaining study patients (30%) were considered trial-eligible. Regardless of the intervention, the median progression-free survival (PFS) and overall survival (OS) were significantly prolonged among patients who were trial-eligible. PFS among trial ineligible patients was 16.2 months compared with 27.3 months for those who were trial eligible. Median OS was 34.2 months vs 58.6 months among trialineligible and eligible patients, respectively, and the 3-year OS rate was 44.4% and 69.4%, respectively. Read more at http://bit.ly/2OOfV2w.

Long-Term Azithromycin Increased Risk of Relapse of Blood Cancers After HSCT Previous studies suggest that azithromycin, a macrolide antibiotic, may prevent bronchiolitis obliterans, a serious lung condition caused by scarring and inflammation in the lungs of patients who have undergone hematopoietic stem cell transplantation (HSCT). In the ALLOZITHRO phase 3 study, researchers randomly assigned 480 patients with hematologic malignancies who underwent HSCT to azithromycin 250 3 times a week or to placebo for 2 years, starting at the time of the conditioning regimen. Primary outcome was airflow decline-free survival, and secondary end points included overall survival (OS) and the occurrence of bronchiolitis obliterans syndrome. After 13 months, the study was terminated as the rate of relapse among patients receiving azithromycin was 33.5% compared with 22.3% for placebo (P =.002). The 2-year OS rate was 57% and 70% in the azithromycin group and placebo group, respectively (P =.02). Airflow decline-free survival was also worsened in patients who received prophylactic azithromycin. Continues on page 12

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IN THE NEWS

PVX-410 Vaccine Delays Disease Progression of SMM to Symptomatic MM Previous studies have suggested that the progression of smoldering multiple myeloma (SMM) to symptomatic multiple myeloma (MM) may be mediated by the immune system; reinforcing the immune system with the PVX410 vaccine may prevent or slow progression to MM. Co-administration with lenalidomide may further enhance an immune response. In this phase 1/2a study, researchers administered 6 doses of PVX-410 with or without lenalidomide 25 mg to 22 asymptomatic patients with SMM. Study patients were human leukocyte antigen A2-positive, and were considered to be at a moderate- to high-risk of progression to MM. Results showed that 19 of the 20 evaluable patients had an immune response to PVX-410 alone or with lenalidomide, but patients who received the combination had a greater percentage increase of tetramer-positive cells and interferon γ–positive cells in the CD3+CD8+ cell population. The combination led to significantly greater mean-fold increases after 2 and 4 vaccinations. Of the 12 patients who received PVX-410 alone, all patients achieved stable disease (SD) as best response, but 5 patients progressed to MM within 12 months of follow up. Of the 9 patients in the combination group, 1 patient had a partial response, 4 patients had a minimal response, and 4 patients achieved SD. The most frequently observed treatment-emergent adverse effects (AEs) included mild-to-moderate injection site reactions, and constitutional symptoms including chills, fatigue, myalgia, and pyrexia. The AE profile of monotherapy and combination therapy were comparable, but those assigned to the combination arm experienced a higher rate and grade of AEs.

Although these findings are limited by early termination, these results show that azithromycin may lead to poorer outcomes. The FDA is recommending that azithromycin not be used in this patient population. Read more at http://bit.ly/2MYDzI3.

Assessing Direct Costs of Treatment-Related AEs in Advanced Melanoma Advanced melanoma is treated with various modalities, including chemotherapy, interleukin-2, interferon, and

biochemotherapies, each associated with separate safety profiles. The financial burden associated with managing these adverse effects (AEs) was explored in this systematic literature review. Researchers identified 7 economic studies conducted between 2007 and 2017 that evaluated the cost of AEs in patients with advanced melanoma. Selected studies assessed direct costs and healthcare resource utilization. The studies were done in multiple countries, and primarily assessed the estimated costs for grade 3 to 4 adverse events. In a US study, monthly costs for AE management accounted for 36.9% of overall healthcare costs for dacarbazine, 30.3% for paclitaxel, 9.2% for temozolomide, 6.4% for vemurafenib, and 4.0% for ipilimumab.

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Read more at http://bit.ly/2NE3IAW.

Expressive Writing Can Improve Psychiatric Symptoms After Cancer Diagnosis Receiving a diagnosis of cancer is a traumatic experience and may lead to negative physical and psychological outcomes such as alexithymia, an inability to identify and describe emotions. Previous studies have shown that expressive writing interventions EWIs are a chance to (EWIs) — interventions aimed to explore emotions allow patients to express their worries and pains through writing — improve the quality of life (QOL) among both healthy persons and patients with disease. In this prospective study, 71 first-time patients with cancer were randomly assigned to an EWI or control group. Patients completed questionnaires assessing alexithymia, psychiatric symptoms, and health-related quality of life at baseline, and completed the same measures 6 months later. Thirty-two patients were available for analysis at follow-up. Results showed that the Pennebaker’s EWI reduced patients’ global psychopathology, which included domains such as anxiety, depression, hostility, paranoid ideation, and interpersonal sensitivity, compared with patients in the control group. Patients in the EWI group also had marginal, but significant improvements in alexithymia. The mental QOL was reduced in both groups, but patients assigned to the EWI had a lower decrease in psychological well-being; a negligible negative effect on patient physical QOL was observed. Read more at http://bit.ly/2IauGdu.

Lenalidomide Plus R-CHOP Effective in High-Burden Follicular Lymphoma Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is a standard front-line treatment for follicular lymphoma (FL), and previous studies

have shown that lenalidomide plus rituximab is a highly effective option as well. In this phase 2 study, researchers sought to determine the effectiveness of lenalidomide plus rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R2-CHOP), a combination of the 2 regimens. For the study, researchers enrolled 80 patients with previously untreated high-burden FL. Induction therapy consisted of 6 cycles of R2-CHOP every 3 weeks followed by 2 rituximab infusions. Results showed that 68 (85%) of study enrollees completed all 6 cycles of R2-CHOP. Overall, 75 of the 80 patients achieved an objective response; by the end of the induction phase, 59 (74%) and 16 (20%) had complete (CR) and partial responses (PR), respectively. At 30 months after enrollment, 55 (69%) patients had a CR. Read more at http://bit.ly/2QWvxm1.

Cytoreductive Therapy Improves Outcomes in PV Key contributors to the higher risk of death among patients with polycythemia vera (PV) include cardiovascular disease and thrombotic events; current recommendations advise that patients with high-risk PV be managed with cytoreductive medications, phlebotomy, and low-risk aspirin. However, real-world adherence to cytoreductive therapies occurs in only a small portion of patients with high-risk PV. In this retrospective analysis, researchers accessed claims data from the Truven Health Marketscan database and evaluated the outcomes of 1823 patients with high-risk PV and 1033 patients with low-risk PV. Pre-index comorbid conditions, such as hypertension, type 2 diabetes, and congestive heart failure, were more common among high-risk patients than among low-risk patients. The most commonly used pre-index cytoreductive therapies for high-risk and low-risk patients, respectively, were hydroxyurea, in 94.7% and 87.5% of patients; anagrelide, in 7.4% and 11.9%; and interferon, in 1.7% and 4.4%. The most commonly used postindex cytoreductive therapies for high-risk and low-risk patients, respectively, were hydroxyurea, in 97.0% and 91.4% of patients; anagrelide, in 4.0% and 2.9%; and interferon, in 2.0% and 8.6%. Results showed that only 42.0% of patients with high-risk PV and 18.9% with low-risk PV received cytoreductive therapy in the pre- or postindex periods overall. Read more at http://bit.ly/2NC9YcJ.

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severity/interference and self-efficacy between the Reimagine arm and the usual care arm. Most patients responded that they would recommend Reimagine to others, and that they felt more resilient upon study completion.

ONCOLOGY NURSE ADVISOR FORUM QUESTIONS & ANSWERS

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

Jiajoyce R. Conway, DNP, CRNP, AOCNP, oncology nurse practitioner at Cancer Care Associates of York in York, Pennsylvania. Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/ PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS, clinical pharmacist specialist, Clear Lake Regional Medical Center, Webster, Texas. Donald R. Fleming, MD, hematologist/oncologist, Cancer Care Center, Davis Memorial Hospital, Elkins, West Virginia. Kerstin L. Lappen, RN, MS, ACNS, ACHPN, clinical nurse specialist, palliative care consult service, Abbott Northwestern Hospital, Allina Health System, Minneapolis, Minnesota. K. Lynne Quinn, RN, MSN, CRNP, AOCNP, director of oncology, Bryn Mawr Hospital and Bryn Mawr Health Center, Bryn Mawr, Pennsylvania.

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

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

HANDLING CHEMOTHERAPY PREMEDICATIONS Are there resources that outline if chemo premeds must be mixed in the laminar air flow hood or can they be mixed in the pharmacy on the counter and not under the hood? — Marsha Ellison, RN, BS Hazardous medications must always be manipulated in an appropriate biological safety cabinet (BSC) to prevent exposure to staff. With nonhazardous medications such as chemotherapy premedications, risks of compounding outside of a hood and cleanroom include the risk of microbial contamination compromising the final product and exposing the patient to an infection risk. The United States Pharmacopeia (USP) <797> chapter on pharmaceutical compounding of sterile preparations provides guidance and outlines requirements for sterile product compounding, including immediate use and low-, medium-, and high-risk preparations. These regulations are currently being revised (anticipated December 2019). For more information, visit www.usp.org/compounding/general-chapter-797. State boards of pharmacy, Joint Commission, other regulating bodies, and your organization may also have additional regulations for sterile product preparation, so I would defer to the advice of your pharmacy leadership for how this information applies to your facility’s sterile compounding needs. — Lisa Thompson, PharmD, BCOP

ANTIOXIDANT INTERACTION WITH CANCER THERAPY What is the concern with antioxidants and chemotherapy or radiation? — Name withheld on request Patients with cancer frequently inquire about supplement use. Many commonly used supplements (eg, vitamin C, coenzyme Q10 (CoQ10), resveratrol, and many others) have antioxidant properties. One concern regarding antioxidant use during cancer treatment relates to how antioxidants work within the body. Some cancer treatments, such as radiation and the anthracyclines (eg, doxorubicin), exert their anticancer effects — at least in part — by generating reactive oxygen species, also known as free radicals, that damage cancer cells, triggering cell death. Antioxidants can neutralize these reactive species, resulting in decreased anticancer effects. This does not mean that patients should avoid all dietary sources of antioxidants, as the amount in many supplements greatly exceeds what would be consumed from a normal diet. However, patients receiving therapeutic radiation or chemotherapy that generates reactive oxygen species should avoid antioxidant-containing supplements during the active phases of their cancer treatment. Because this varies depending on the treatment, patients should be advised to report potential supplement use to their care team. — Lisa A. Thompson, PharmD, BCOP

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

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 15

hile estimates show that the majority of people search online for information about health, the quality of the information sources is not always clear.1 For conditions surrounded by prognostic uncertainty, such as pancreatic cancer, information that patients find on the internet can have a profound effect on their knowledge and, therefore, their decisions. Optimal patient education materials harbor the potential to fill a knowledge gap in a way that encourages patients to engage with healthcare providers effectively, explained researchers at Beth Israel Deaconess Medical Center in Boston, in a recent report.2 Suitability of patient educational materials needs to be assessed in consultation with members of the intended audience in order for materials to be effective, explained the researchers. Their report marks a follow-up to an earlier study that focused on readability and accuracy of online health content regarding pancreatic cancer.3 The authors of this study noted that poor health literacy combined with limited access to health care, lack of support, and acute illness can result in poor clinical outcomes. At the same time, patients with recently diagnosed cancer are likely to look online for materials. “This immediate need for simple, high-yield information combined with the advantages of widespread Internet access create a window of opportunity for website developers to recruit an avid audience, motivate the pursuit of professional care, and potentially modify

How Accurate Is the Cancer Information Your Patients Find Online? Megan Garlapow, PhD

the course of the disease among some patients,” explained the researchers. STUDY DESIGN In the current study, 10 volunteers assessed the suitability of online patient education materials related to pancreatic

cancer. Eligibility was limited to adults and based on fluency in English, ability to use a computer, and lack of the following: education in health sciences, personal or family experience with pancreatic cancer, and caregiving experience with cancer. “Increasing the number of participants would increase precision of results, but still with 10 participants it is possible to obtain valid results that should be corroborated by other studies,” said first author Alessandra Storino, MD, a general surgery resident PGY-3 at Beth Israel Deaconess Medical Center, in an interview with Oncology Nurse Advisor. Participants examined 50 treatmentoriented websites chosen using location-based Google searches utilizing the phrase “pancreas cancer” with additional search terms from the following, with 10 sites for each: surgery, chemotherapy, clinical trials, radiotherapy, or alternative therapies. Sites could not have limitations such as fees or video-only content, and had ownership attributed to academic, government, media, private, or nonprofit categories. Suitability was measured by the volunteers using a standardized suitability scoring method applied to various website features, including content, cultural appropriateness, learning stimulation and motivation, literacy demand, and visual features such as graphics, type, and layout. Suitability scores from 0% to 39% were considered “not suitable,” from 40% to 69% were considered “adequate,” and from 70% to 100% were considered “superior.” Readability was assessed using 5 standardized metrics. A panel including an

Information that patients find on the internet can have a profound effect on their knowledge and, therefore, their decisions. 16 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

NAVIGATOR NOTES

NAVIGATOR NOTES oncologist, a surgeon, and a radiation oncologist determined accuracy based on best available evidence. “Best available evidence is defined as current, upto-date, non-controversial management as indicated by the medical literature,” noted Dr Storino. RESULTS The average age of the evaluators was 30 years (range, 23-63). Half of the evaluators (n=5) were women. Seven volunteers had completed 4 years of college, and 1 had completed 2 years of college. Dr Storino explained that patients with pancreatic cancer might participate more actively in online searches, but she cautioned against the vulnerabilities that patients with a recent diagnosis can experience: “Patients often search online right after diagnosis, a time of uncertainty and distress, thereby making them more vulnerable to misleading information. Vulnerable populations face at least the same obstacles as healthy volunteers.” Though clinical trial websites were ranked overall the most accurate, they and alternative therapy websites shared the same low suitability score despite the striking difference in accuracy. Surgery and radiotherapy websites were rated more suitable than clinical trial or alternative therapy websites. Chemotherapy websites were less suitable than surgery websites. Radiotherapy websites were the second most accurate, with chemotherapy and surgery websites close behind, though radiotherapy websites were the most difficult to read. By ownership, government websites were easiest to read. Nonprofit websites were easier to read than media websites. Government, nonprofit, and academic websites were among the most accurate. Suitability scores were not significantly different among most affiliations; this includes privately owned websites,

which were lower in accuracy but relatively high in suitability. A lthough readabilit y was not enhanced by visual content, suitability scores increased by 11% for sites that included pictures and 13% for sites that included videos. Less accurate websites, however, were significantly more likely to contain visual content. Neither readability nor accuracy correlated with suitability of content for this pool of participants with aboveaverage educational levels. The volun-

Visual appeal could affect patients’ engagement with the material. teer audience judged websites from all study categories to be sufficiently suitable, in contrast to expectations based on assessments of prior researchers. LIMITATIONS, CONSIDERATIONS, AND CONCLUSIONS

The study authors suggested evaluations of lay readers should be considered when professionals judge content suitability. In addition to ensuring accuracy and readability, content creators and healthcare providers must recognize that many patients are drawn to materials emphasizing visual content. These patients may also want patient education materials that address their immediate concerns. “Moreover, our data suggest that more accurate websites were less likely to present pictures,” the authors wrote. The visual appeal of a website could affect patients’ engagement with the presented material. “Audiences for online PEM [patient education material] on pancreatic cancer may be drawn

to low-quality websites using attractive displays, while high-quality websites become potentially unproductive if they do not implement successful engagement methods,” the authors concluded. Patients engage with online health information at the highest rate immediately following a cancer diagnosis, according to the researchers, who stated that what these patients need is high-quality online patient educational content that is simple but meaningful and encourages them to seek professional care. “Most of the research on online education materials has focused on improving text readability (to ensure that most patients are able to understand the content) and accuracy (to ensure that content is unbiased and factual),” said Dr Storino. “Our study highlights the importance of suitability, which focuses on appropriately targeting readable and accurate content to the needs of the audience. This is important because suitable materials are more likely to be preferred and chosen by intended audiences over nonsuitable materials,” she concluded. ■ Megan Garlapow is a medical writer based in Tempe, Arizona. REFERENCES 1. Fox S, Duggan M. Health Online 2013. Pew Research Center website. http://www.pewinternet.org/2013/01/15/health-online-2013/. Published January 15, 2013. Accessed August 1, 2018. 2. Storino A, Guetter C, Castillo-Angeles M, et al. What patients look for when browsing online for pancreatic cancer: the bait behind the byte [published online ahead of print July 3, 2018]. World J Surg. doi: 10.1007/ s00268-018-4719-2. 3. Storino A, Castillo-Angeles M, Watkins AA, et al. Assessing the accuracy and readability of online health information for patients with pancreatic cancer. JAMA Surgery. 2016;151(9):831-837.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 21

FEATURE | Patient Navigation

Including Oral Care in Cancer Care Plans Improves Outcomes A visit to the dentist before surgical treatment of cancer can reduce the risk of postoperative pneumonia, a potentially fatal adverse event. MEGAN GARLAPOW, PhD

reoperative oral care by a dentist decreased postoperative complications in patients undergoing surgery for cancer. Dental care was associated with reductions in both postoperative pneumonia and all-cause mortality.1 The findings suggest oncology nurse navigators should consider integrating oral care by a dentist into preoperative care as a way to improve clinical outcomes and to reduce postoperative mortality.

SIGNIFICANCE OF ORAL CARE

Dental plaque harbors pneumonia-causing bacteria that increase the risk of developing postoperative pneumonia

Preoperative dental care could reduce postoperative complications in cancer patients. For example, aspiration of oral and pharyngeal secretions and bacteria can cause postoperative pneumonia, which is sometimes fatal. The adverse effect, however, occurs more frequently in patients undergoing surgery for esophageal cancer.2 In one study of digestive tract surgery in elderly patients (aged 60 to 98 years), postoperative oral care resulted in fewer abnormal pulmonary sounds, including dry or moist rales, and reduced bacterial load across several sites compared with a control group that did not undergo postoperative dental care.3 Although the oral care in this study included procedures executed by the patient, occurred postoperatively, in patients who did not have cancer, these results suggest oral care is an important part of optimizing clinical outcomes, particularly improved pulmonary function.3 Results from a retrospective analysis of patients with esophageal cancer who underwent

22 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

esophagectomy found the absence of perioperative dental care was associated with increased incidence of postoperative pneumonia. In this study, perioperative dental care involved oral care from a dentist or dental hygienist prior to the procedure and instructions for patient-administered postoperative oral care. Researchers used propensity score matching to control for covariates that could affect receiving perioperative oral care.4 In another study, researchers assessed the bacterial profile contained in preoperative oral plaque in patients who underwent esophagectomy for thoracic esophageal cancer. The bacterial profile of the sputum was also analyzed in patients who went on to develop postoperative pneumonia.5 Although the study population was small (N = 39), the results demonstrated that the presence of pathogenic bacteria in preoperative plaque was more common in those patients who later developed pneumonia. Furthermore, the pathogenic bacterial profile of the preoperative plaque aligned with that of the postoperative sputum in those patients who developed pneumonia. “Pathogens in preoperative dental plaque are risk factors for postoperative pneumonia following thoracotomy in patients with thoracic esophageal cancer,” concluded the researchers.5 Preoperative oral care could debride plaques that harbor pneumonia-causing bacteria. Taken together, these results suggest perioperative oral care could reduce the risk of developing postoperative pneumonia in part by decreasing the bacterial load. This reduction could decrease aspiration of pneumonia-causing bacteria, with the resulting decrease in pneumonia correlating with improved survival. EFFECT ON OUTCOMES In a recent study, researchers in Japan used a nationwide administrative claims database in a retrospective cohort study to identify 509,179 patients who underwent surgery for head and neck, gastric, esophageal, lung, colorectal, or liver cancer between May 2012 and December 2015. Of these patients, 16.0% (81,632) received preoperative oral care from a dentist.1 The primary end points of this study were postoperative pneumonia and all-cause mortality in the initial 30 days following surgery. A little more than 3% of patients (15,724) experienced postoperative pneumonia, and 0.34% of patients (1,734) died within the first 30 days following surgery.1 After adjusting for potential confounding factors, 3.28% of patients who underwent preoperative oral care from a dentist experienced postoperative pneumonia, a significant

decrease from the 3.76% of patients who did not undergo preoperative oral care and developed postoperative pneumonia (risk difference, –0.48%; 95% confidence interval [CI], –0.64 to –0.32).1 Similarly, all-cause mortality within the first 30 days after surgery was 0.30% in patients who underwent preoperative oral care from a dentist vs 0.42% in patients who did not receive oral care (risk difference, –0.12%; 95% CI, –0.17 to –0.07).1 CONCLUSIONS Guidelines are not yet established for including preoperative and perioperative oral care for patients undergoing surgery as part of their planned cancer therapy. One group assessing bacterial load and salivary function in patients with esophageal cancer noted, “[T]here is a great need for an oral health care clinical approach for esophagectomized patients during the perioperative period.”6

The accumulation of study results suggests healthcare providers should recommend preoperative oral care for patients with cancer. In addition, prospective, randomized studies are needed to address which specific oral care procedures are most efficacious at improving clinical outcomes, reducing pneumonia, and reducing mortality in cancer patients undergoing surgery. In the absence of such studies, the accumulation of study results still suggests healthcare providers should recommend preoperative oral care for patients with cancer, particularly those with gastrointestinal, esophageal, and/or head and neck cancers. Such preoperative care could reduce the pathogenic bacterial load in the oral cavity, thereby reducing the risk of postoperative pneumonia developing and its associated mortality risk. Ideally, preoperative oral care would include instruction on postoperative oral hygiene to further improve outcomes. ■ Megan Garlapow is a medical writer based in Tempe, Arizona. The references for this article can be read in the online version, accessible through this easy link: https://bit.ly/2zwaBMi.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 23

FEATURE | Patient Assessments

Fitness Wearables Are Finding a Place in Oncology Care Wearable activity monitors offer oncology care teams an unbiased glimpse into patients’ health behaviors and improved reports on performance status. BETTE WEINSTEIN KAPLAN

Wearable activity monitors can mitigate the potential for patient bias to skew self-reports.

hen wearable activity monitors first came on the market, it seemed like they were on everyone’s wrists. It was not long before they surfaced as mobile phone apps, making it convenient for anyone to monitor their activity, health, and fitness. Now the category of fitness wearables is not just basic activity wristwear; it includes a variety of jewelry such as bracelets and smart watches that track the wearer’s step counts and calories expended. These devices also log behavioral, sleep, and other physiologic metrics and can be synced with a computer or smartphone app that summarizes the data collected. Sales of smart watches alone are predicted to reach 141 million units by the end of 2018, and according to Forbes.com, 240.1 million wearable devices of different types will be produced in 2021.1,2 Part of the reason for their popularity is that the medical community finds wearables ideal for tracking a patient’s health, and their use in the medical field is widespread. Wearables are particularly useful in oncology, since performance scales that evaluate a patient’s functioning and self-care can be limited. Although valuable, these measures may require some self-reporting from the patient and objective reporting from the clinician; in either case, the patient’s status could be misinterpreted, and this could affect treatment. Patients may have recall bias, or a bias toward enrolling in a clinical trial or receiving a different therapy, and they may skew their self-report toward this. Further, the commonly used performance status assessments

24 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

are static and only performed during clinic visits, whereas a patient’s condition and performance are always in a state of flux. Gil lian Gresham, PhD, of the Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai Medical Center in Los Angeles, California, and Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, and colleagues undertook a study to determine the feasibility of using wearable activity monitors to assess performance status in patients with advanced cancer. The device used was the Fitbit Charge HR®, which tracks step and stair counts, heart rate, calories expended, and sleep patterns.3 The study enrolled 37 patients, 20 men and 17 women, with a median age of 62. Most patients had stage 4 gastrointestinal cancer; 2 had advanced stage 3 pancreatic cancer and 1 had stage 3B endocervical serous carcinoma. The participants in this study had lower levels of physical functioning and higher levels of fatigue and pain than the remaining cancer population. ACTIVITY DATA CORRELATES WITH PERFORMANCE STATUS

Over a 2-week period, the fitness trackers showed that the patients walked approximately 3700 steps (1.7 miles) per day, climbed an average of 3 flights of stairs per day, and slept an average of 8 hours per night as measured with the wearable activity monitor. Patients’ average resting heart rate was 68 beats per minute. The more active the patients were, the better their disease course was. An average increase of 1000 steps per day correlated with a significantly lower risk for hospitalizations, reduced adverse events, and increased survival. Patients who walked fewer than 1000 steps per day survived an average of 2 months, while patients who walked between 1000 and 2000 steps per day survived an average of 5.5 months. Reduced odds of hospitalizations and toxicity occurrences were associated with a higher number of stairs climbed. Conversely, patients who reported higher levels of fatigue showed decreased step counts, shorter walks, and fewer stairs climbed. Although nightly sleep duration was not associated with the frequency of hospitalizations or the occurrence of adverse events, the researchers observed a statistically significant correlation of sleep with overall survival.3

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The investigators described a prior study that evaluated whether a different brand of fitness tracker, Garmin, could predict the likelihood of hospitalization in 38 patients undergoing concurrent curative radiation and chemotherapy for head and neck, gastrointestinal, or lung cancer. That study

Wearables are particularly useful in oncology, since performance scales that evaluate a patient’s functioning and self-care can be limited. found that patients who walked an average of 5103 steps per day with an increase of 1000 steps per day had a 38% reduced risk for hospitalization.4 Gresham and colleagues noted that their findings and those of the Garmin study demonstrate the feasibility of objective activity monitoring in predicting clinical outcomes such as hospitalizations in patients with cancer. They call for larger clinical trials to explore the possibilities posed by the use of fitness wearables in cancer care. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Smartwatch unit sales worldwide from 2014 to 2018 (in millions). Statista website. www.statista.com/statistics/538237/global-smartwatch-unitsales. Accessed August 15, 2018. 2. Lamkin P. Wearable tech market to double by 2001. Forbes website. www.forbes.com/sites/paullamkin/2017/06/22/wearable-tech-marketto-double-by-2021/#76623f8fd8f3. Posted June 22, 2017. Accessed August 15, 2018. 3. Gresham G, Hendifar AE, Spiegal B, et al. Wearable activity monitors to assess performance status and predict clinical outcomes in advanced cancer patients [published online July 5, 2018]. NPJ Digital Med. doi: 10.1038/s41746-018-0032-6 4. Ohri N, Kabarriti R, Bodner WR, et al. Continuous activity monitoring during concurrent chemoradiotherapy. Int J Radiat Oncol Biol Phys. 2017;97(5):1061-1065.

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FEATURE | Cancer Prevention

How Effective Are Skin Cancer Screening Programs? Although the programs have led to diagnoses that would have otherwise been missed, their overall public health benefit remains unclear. BRYANT FURLOW

Support for clinician-conducted visual skin cancer screening is mixed, but counseling is recommended for patients younger than 24 and those with fair skin.

n anticipated 91,270 Americans will receive a diagnosis of malignant melanoma this year, and 9320 will die of the disease, according to the US National Cancer Institute.1 Incidence rates have climbed steadily in recent decades but there have been modest reductions in mortality since 2006, likely due in part to advances in targeted treatment options. The 5-year overall survival rate in the United States exceeds 90%.1 Melanoma incidence rates rose by 1.5% a year, on average, between 2006 and 2015 — but mortality rates declined by 1.2% per year during the same period.1 Skin cancer screening programs are intended to improve the chances of early detection and treatment of melanoma, but the evidence that they achieve that goal remains mixed.2,3 As a result, skin cancer screening recommendations vary between countries.4,5 The US Preventive Services Task Force (USPSTF) concluded in 2016 that the available research offered insufficient evidence to determine the potential harms — such as anxiety or overtreatment — and benefits of clinician-conducted visual skin cancerscreening examinations.2 Several US medical societies, including the American College of Physicians, American College of Preventive Medicine, and the American Cancer Society, do not recommend skin cancer screening.6 Germany established the world’s first nationwide skin cancer screening program in 2008, yielding a modest and temporary decrease in melanoma mortality.5 By 2014, however, the

26 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

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FEATURE | Cancer Prevention program had not achieved a decrease from 2007 melanoma mortality rates.5 In the United States, the American Academy of Dermatology’s SPOTme® Skin Cancer Screening Program has provided more than 2 million no-fee, volunteer-led skin cancer screenings since it was established in 1985, leading to the detection of more than 30,000 suspected melanomas.6 It is one of the largest cancer screening programs, second only to the US Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program.6 A recent review of the SPOTme program’s first 30 years of operation found that participating clinicians have performed approximately 100,000 screenings each year since 1990.6 That program has led to detection and diagnosis of melanomas among thousands of people, including the 9% of screenees overall — and 12% of those with a melanoma diagnosis — who were uninsured.6 “In all, 72% of the screenees met the US Prevention Services Task Force criteria for high risk of melanoma,” the researchers reported.6 “Among persons with clinically diagnosed melanoma, 47% would not have otherwise seen a doctor for a skin examination.”

Hundreds of smart-phone applications are available for skin self-examinations, tracking the growth of suspicious moles, teledermatology, and patient education, but few well-designed studies have been conducted to evaluate their safety or efficacy.7,8 A 2016 systematic review concluded that more objective measures are needed to evaluate smart phone skin cancer apps.7 For example, of 6 studies that measured sunburn incidence in evaluating skin cancer education apps, only one found a significant reduction in consumers’ self-reported sunburns.7 In 2018, the USPSTF recommended that clinicians counsel young children and their parents, adolescents, and young adults with fair skin to minimize sun exposure, and that adults older than 24 be counseled “selectively” despite evidence that the benefits of counseling are lower for adults older than 24.9 ■ Bryant Furlow is a medical reporter based in Albuquerque, New Mexico. REFERENCES 1. Cancer Stat Facts: Melanoma of the skin. National Cancer Institute website. https://seer.cancer.gov/statfacts/html/melan.html. Accessed September 19, 2018. 2. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for skin cancer: US Preventive Services Task

The SPOTme Skin Cancer Screening Program has led to detection and diagnosis of melanomas among thousands of people. ®

Force Recommendation Statement. JAMA. 2016;316(4):429-435. 3. Shellenberger RA, Kakaraparthi S, Tawagi K. Melanoma screening: thinking beyond the guidelines. Mayo Clin Proc. 2017;92(5):692-698. 4. Ebell MH, Thai TN, Royalty KJ. Cancer screening recommendations: an international comparison of high income countries. Public Health Rev. 2018;39:7. 5. Stang A, Garbe C, Autier P, Jöckel KH. The many unanswered questions related to the German skin cancer screening programme. Eur J Cancer. 2016;64:83-88.

Beneficiary demographics suggest possible disparities in access to skin cancer screening. Ninety percent of SPOTme screenees were white, compared to approximately 2% and 4% who were black and Hispanic, respectively, although it is important to note that fair skin is a key risk factor for melanoma.6 Close to two-thirds (62%) of screenees were women.6 Nearly half (48%) of screenees with melanoma had never previously had their skin checked for cancer.6 “[T]he SPOTme population is older and whiter than the general US population, both of which are independent risk factors for skin cancer,” the researchers noted.6

6. Okhovat JP, Beaulieu D, Tsao H, et al. The first 30 years of the American Academy of Dermatology skin cancer screening program: 1985-2014 [published online July 26, 2018]. J Am Acad Dermatol. doi: 10.1016/j.jaad.2018.05.1242 7. Finch L, Janda M, Loescher LJ, Hacker E. Can skin cancer prevention be improved through mobile technology interventions? A systematic review. Prev Med. 2016;90:121-132. 8. Chao E, Meenan CK, Ferris LK. Smartphone-based applications for skin monitoring and melanoma detection. Dermatol Clin. 2017; 35(4):551-557. 9. US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, et al. Behavioral counseling to prevent skin cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(11):1134-1142.

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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! 28 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

CASE STUDY | Myeloproliferative Neoplasms

A Case Study on PV From Diagnosis Through Optimal Management This case follows a 35-year-old man with polycythemia vera from presentation in the ED through initiating and modifying treatment with phlebotomy and hydroxyurea, and eventually achieving optimal management of symptoms and CBC with ruxolitinib. What is the next step in working up a patient who presents with erythrocytosis? WORKUP/RESULTS: Assessment in the hematology/oncology clinic includes a thorough history, repeat CBC with differential, serum erythropoietin (EPO) level, peripheral blood JAK2 mutation analysis, and a physical examination. Lindsey Lyle, MS, PA-C Blood Cancers and Bone Marrow Transplant Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado

PRESENTATION: A 35-year-old man

presents to an emergency department (ED) complaining of fatigue of several months’ duration and the development of chest pain. He has a past medical history of metastatic testicular cancer that was successfully treated in 2004; he currently has no evidence of disease. An EKG shows no evidence of myocardial infarction or concern for pulmonary embolism, and a chest radiograph is unremarkable. Laboratory studies revealed WBC 18,000/µL, hematocrit (Hct) 67%, hemoglobin 23 g/dL, and platelets 600,000/µL. The patient is clinically stable so he is discharged from the ED and told to follow-up with a hematologist.

Pertinent History: No prior history of

cardiac or pulmonary disease, and no prior thrombosis. Laboratory Test Results: CBC is consistent with trilineage myeloproliferation: WBC 21,000/µL with no blasts, Hct 66%, and platelets 650,000/µL; EPO is undetectable; and JAK2 mutation analysis is positive. Imaging: Echocardiography was performed due to complaints of chest pain at presentation; however, no abnormal findings are noted. Physical Examination Findings: BP 150/88, otherwise vital signs are within normal limits. The patient is wellappearing, thin, with flushed cheeks. Cardiac and pulmonary examination findings are unremarkable. No palpable hepatosplenomegaly and no peripheral edema were noted.

The patient did not undergo bone marrow biopsy; however, a diagnosis of polycythemia vera (PV) is made based on the following major diagnostic criteria: Hct greater than 49%, subnormal EPO level, and the presence of JAK2 V617F mutation. Of note, at the time of this diagnosis, bone marrow biopsy showing hypercellular bone marrow with trilineage proliferation was not a major diagnostic criterium, but this was changed with the 2016 WHO classification and diagnostic criteria for PV. What is the greatest clinical concern given the above laboratory test findings?

Patients with PV are at higher risk for developing venous and arterial blood clots, which may result in serious events including heart attack and stroke. To reduce this risk, controlling hematocrit levels to less than 45% and starting low-dose aspirin is extremely necessary. CBC Monitoring/Phlebotomy Course:

The patient was started on low-dose aspirin and treated with phlebotomy. In the first month of treatment, the patient required 9 phlebotomies to achieve a Hct of less than 45%, but then was able to go a few months between

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 29

CASE STUDY | Myeloproliferative Neoplasms

procedures. BP readings normalized with phlebotomy. Unfortunately, frequency of procedures was increasing prior to transfer of care to our clinic, and the patient had been undergoing phlebotomy monthly for the last 3 months. Laboratory test results on presentation to our clinic were WBC 22,000/ µL; Hct 49%; platelets 774,000/µL; ferritin 9 ng/mL; and very low EPO level. Because of the patient’s elevated WBC count and need for frequent phlebotomy, we recommended initiating cytoreductive therapy with hydroxyurea; however, the patient declined the treatment. Phlebotomy continued every 2 to 3 months to maintain a target Hct of less than 45%. Platelets started to increase further, and when they reached 1.2 million, von Willebrand factor (vWF) activity was checked, noted to be low, and low-dose aspirin was temporarily put on hold. Facing the risk of bleeding with extreme thrombocytosis, persistent need for phlebotomy, and leukocytosis, the patient was now amenable to starting hydroxyurea therapy. In addition, he had developed symptoms of disease including bone pain, headaches, and fatigue that were preventing him from working full time.

continued the hydroxyurea as dosed for the next 3 months. Symptomatically, the patient felt better after starting hydroxyurea, presumably due to better disease control, and returned to work full-time. However, after 4 months of treatment at this dose, he still required phlebotomy every other month; therefore, the hydroxyurea dose was increased to 1500 mg orally daily. Follow-up: The patient was monitored

monthly and continued to require phlebotomy every other month. His platelets were well-controlled, but WBC started to drop to less than the lower limits of normal. In addition, the patient developed hypertension and was referred to a cardiologist for antihypertensive therapy, as optimal control of cardiovascular risk factors is necessary to reduce the risk of cardiovascular events in patients with PV. After 5 months on the higher dose of hydroxyurea, the need for phlebotomy remained persistent. The hydroxyurea dose could not be increased any further due to a risk of neutropenia; therefore, alternative therapeutic options were discussed with the patient.

for phlebotomy despite receiving the maximally tolerated hydroxyurea dose. How would you approach the transition from hydroxyurea to ruxolitib? Therapy Transition: Initiating ruxoli-

tinib in a patient with PV may require overlap of therapy at the beginning. Baseline CBC will help guide the need for continued hydroxyurea. In this case, the hydroxyurea dose was reduced to 500 mg once daily for 1 week to allow WBC to recover prior to starting ruxolitinib and the patient had just undergone phlebotomy. Baseline CBC results on ruxolitinib initiation were WBC 8700/µL with an absolute neutrophil count (ANC) of 6000/mm3, Hct 43%, and platelets 500,000/µL. Ruxolitinib starting dose for PV is 10 mg twice daily. This patient started ruxolitinib while continuing hydroxyurea 500 mg once daily for 1 more week; then hydroxyurea was discontinued. To date, 3 months after ruxolitinib initiation, the patient has not required a phlebotomy and disease symptoms are controlled. Most recent CBC results include WBC 4500/µL, ANC 3000/ mm3, Hct 42%, platelets 335,000/µL.

Alternative Therapies: Pegylated interTreatment With Hydroxyurea: Hy-

droxyurea therapy was started at a dose of 1000 mg orally daily and was tolerated without adverse effects. WBC, RBC, and platelets all responded well. Within 1 month, WBC decreased from 23,900/µL to 10,600/µL, and platelets decreased from 884,000/µL to 204,000/ µL. Hct increased from 43.3% to 46.1%, likely because of the length of time since his last phlebotomy. Repeat vWF activity showed this had normalized with the reduction in platelet count, and low-dose aspirin was resumed. The patient underwent phlebotomy and

feron was previously discussed with the patient at treatment initiation; however, he did not want to risk the potential for flulike symptoms because of his frequent travel for work. He was still of this mindset; therefore, we did not pursue treatment with this biologic agent. We discussed treatment with ruxolitinib, a JAK1/2 inhibitor that is FDA approved in the setting of uncontrolled blood counts despite treatment with hydroxyurea as well as intolerance of hydroxyurea. His disease fits into the refractory category, proving to be more advanced with the persistent need

How frequently should this patient be monitored?

Monitoring CBC every 2 weeks when initiating new therapy is reasonable. This ensures that phlebotomy is not required and that WBC and platelet counts are also well-controlled. Monitoring for significant cytopenias, which can occur as a result of therapy or in some cases progression to myelofibrosis, is also important. Once a patient is stable, reducing follow-up to once monthly and then every 3 months is generally acceptable. ■

30 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

Write for ONA! Oncology Nurse Advisor offers clinical updates and evidence-based guidance to the oncology nurse community and includes regular coverage of topics such as the safe handling and administration of chemotherapy drugs, side effect management, new developments in specific cancers, palliative care, communication with patients and family, and cancer survivorship. We welcome contributions from readers in the following categories: Oncology Nurse Advisor Forum: Answers to clinical questions and advice for clinical problems. Readers may submit questions and requests for advice that are 50 to 100 words long. The author should include full name and degrees, name of institution or practice, and city and state. Feature article: Oncology Nurse Advisor welcomes feature articles on the administration and handling of chemotherapy drugs; side-effect management; communication with patients, families, and colleagues; whatâ&#x20AC;&#x2122;s new in the treatment of specific cancers or cancer-related conditions; survivorship issues; patient navigation; and other topics of interest to oncology nurses. Manuscripts should be 1200 to 2000 words long and should include a brief reference list. Reflections: These are brief, reflective essays on a topic related to oncology practice or narratives recounting a meaningful experience with a patient. Manuscripts should be 800 to 1200 words long. Case Study: This department focuses on clinical cases of interest to oncology nurses. Manuscripts should be written in the standard case-followed-by-discussion format and should be 1500 to 2000 words long. A brief reference list may accompany the discussion section. Please include a list of 3 to 5 take-home points (teaching points) for the reader. The PDF template in our Author Guidelines is an easy, step-by-step guide for writing up your Case Study. Ask a Pharmacist: In this department, our oncology pharmacist answers readersâ&#x20AC;&#x2122; drug-related questions. Questions should be 50 to 100 words. The author should include full name and degrees, name of institution or practice, and city and state. See our author guidelines, available at www.OncologyNurseAdvisor.com, for more details.

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JOURNAL REVIEW

he models used to identify those persons at highest risk for lung cancer leave significant room for improvement, according to researchers at the National Cancer Institute Division of Cancer Epidemiology & Genetics, Biostatistics Branch. In a report published in the Annals of Internal Medicine, they report that only 4 models (the Bach model, PLCOM2012, LCRAT, and LCDRAT) are highly accurate at predicting risk in ever-smokers for screening.1 Hormuzd Katki, PhD, and colleagues report that ending the epidemic of smoking-related illness requires continued progress in smoking cessation and prevention. However, they have found that effectively and efficiently targeting lung cancer screening to persons at highest risk has been less than optimal. This study revealed that 4 lung cancer risk models appear to perform best in selecting US ever-smokers for screening; however, the models should be further refined to improve their performance in certain subpopulations. THE STUDY A variety of lung cancer risk models are currently in use. Dr Katki’s team sought to measure the performance of each model in selecting ever-smokers for screening. They searched MEDLINE for studies published between January 1, 2000, and December 31, 2016, using the terms lung-cancer, risk, prediction, and model. Only models that provided a cumulative risk estimate for primary

Choosing an Effective Lung Cancer Screening Model John Schieszer, MA

lung cancer or lung cancer mortality for at least 1 time point were included. The team compared the US screening populations selected by 9 lung cancer risk models: the Bach model; the Spitz model; the Liverpool Lung Project (LLP) model; the LLP Incidence Risk Model (LLPi); the Hoggart model; the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Model 2012 (PLCOM2012); the Pittsburgh Predictor; the Lung Cancer Risk Assessment Tool (LCRAT); and the Lung Cancer Death Risk Assessment Tool (LCDRAT). For this investigation, the 9 prominent lung cancer risk models were applied to a representative sample of the US population, and the similarities and differences among the ever-smokers selected for CT lung cancer screening by each model were analyzed.

WHAT WAS LEARNED The US Preventive Services Task Force (USPSTF) recommends CT screening for lung cancer for smokers aged 55 to 80 years who have a history of at least 30 pack-years of smoking and stopped smoking no more than 15 years prior. Individualized risk calculators that account for demographic, clinical, and smoking characteristics are hoped to greatly improve the effectiveness and efficiency of CT screening programs. The study revealed that the 4 bestperforming models (Bach model, PLCOM2012, LCRAT, LCDRAT) had the overall highest discrimination. These models also had the highest sensitivity. Study observations suggested that any of these models could be used to select US smokers who are at the greatest risk for lung cancer incidence or death. The authors noted that each of the 4 models was validated in external cohorts and has a readily available online risk calculator. Overall, they showed better agreement on size of the screening population (7.6 million to 10.9 million) and achieved consensus on 73% of persons selected. IMPLICATIONS FOR NURSES Thoracic oncologist Inga T. Lennes, MD, MPH, MBA, of the Massachusetts General Hospital Cancer Center, in Boston, said these findings are an important advance because there is an urgent need to improve lung cancer screening models. “There has been inconsistent inclusion of patients with a history of Continues on page 44

Individualized risk calculators that account for demographic, clinical, and smoking characteristics are hoped to greatly improve the effectiveness and efficiency of CT screening programs. 32 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

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

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Visit www.OncologyNurseAdvisor.com today.

JOURNAL REVIEW

djuvant endocrine therapy and chemoendocrine therapy appear to have similar efficacy in women with hormone receptor (HR)-positive, HER2-negative, axillary node-negative breast cancer whose Oncotype DX recurrence score (RS) is in the middle of the range, according to a study published in the New England Journal of Medicine. A subset of women aged 50 or younger with an RS of 21 to 25 derived some benefit from chemotherapy, with 7% fewer distant recurrences when chemotherapy was given, explained J.A. Sparano, MD, professor of medicine & obstetrics, gynecology, and women’s health at the Albert Einstein College of Medicine, and associate chairman for clinical research in the Department of Oncology at Montefiore Medical Center, Bronx, New York. In addition, distant recurrence rates at 9 years for those treated with endocrine therapy alone was 3% in women whose RS was less than 11, and 5% in women whose RS was 11 to 25. THE STUDY

The 21-gene assay is used to quantify the risk of distant recurrence in women with HR-positive early breast cancer. Women with a high RS are predicted to benefit from chemotherapy. However, the prediction value for women with a midrange RS (11 to 25) has been controversial. In a prospective trial involving 9719 women aged 18 to 75 years, 69% (6711 women) had a midrange RS. These

Chemotherapy Still Beneficial With Midrange 21-Gene RS John Schieszer, MA

women were randomly assigned to chemoendocrine therapy or endocrine therapy alone. The researchers sought to determine the noninferiority of endocrine therapy alone for achieving invasive disease-free survival (ClinicalTrials.gov Identifier, NCT00310180), defined as “freedom from invasive disease recurrence, second primary cancer, or death.” WHAT WAS LEARNED Endocrine therapy was found to be noninferior to chemoendocrine therapy in the analysis of invasive disease-free survival with a hazard ratio of 1.08. In the study, the two treatment arms had similar rates of invasive disease-free survival (83.3% in the endocrine-therapy group vs 84.3% in the chemoendocrine-therapy group) at 9 years. The findings were similar for freedom from disease recurrence at a distant site (94.5% vs 95.0%) and at a distant or local/regional site (92.2% vs 92.9%).

No differences were found in terms of overall survival between the 2 arms (93.9% vs 93.8%). However, the chemotherapy benefit for invasive disease-free survival varied with the combination of RS and age. Women 50 or younger with a RS of 16 to 25 derived some benefit from chemotherapy. IMPLICATIONS FOR NURSES These new findings contrast with those of previous biomarker validation studies. Those previous studies used archival tumor specimens. In this study, the rate of nonadherence to the assigned treatment was 12% overall, but investigators were able adjust the sample size to compensate for it. The investigators concluded that the 21-gene assay may identify up to 85% of women with early breast cancer who can be spared adjuvant chemotherapy. In addition, the assay may be especially beneficial to women older than 50 who have a recurrence score of 25 or lower, as well as women 50 and younger with a recurrence score of 15 or lower. Oncology nurses now can more precisely counsel women about the benefits and limitations of the 21-gene assay based on their RS score. ■ John Schieszer is a medical reported based in Seattle, Washington. REFERENCE Sparano JA, Gray RJ, Makower DF, et al. Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med. 2018;379(2):111-121.

The assay may be especially beneficial to women older than 50 who have a recurrence score of 25 or lower, as well as women 50 and younger with a recurrence score of 15 or lower. 34 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

STAT CONSULT Talimogene Laherparepvec (Imlygic) Drug type

• Genetically modified oncolytic viral therapy

Indication

• Unresectable cutaneous, subcutaneous, and nodal lesions in patients with recurrent melanoma after initial surgery ——Limitations: Not shown to improve overall survival or effect visceral metastases Mechanism of Action

• Talimogene laherparepvec replicates within tumors and produces the immune stimulatory protein granulocytemacrophage colony-stimulating factor (GM-CSF) • Causes tumor lysis, followed by a release of tumor-derived antigens, which together with virally derived GM-CSF may promote an antitumor immune response • The exact mechanism of action is unknown Dosage

• Initial dose ——Maximum 4 mL of 106 (1 million) plaque-forming units (PFU) per mL • Second dose ——Maximum 4 mL of 108 (100 million) PFU/mL 3 weeks after initial dose • All subsequent treatments ——Maximum 4mL of 108 PFU/mL 2 weeks after previous treatment • Inject largest lesion(s) first; prioritize injection of remaining lesion(s) based on lesion size until maximum injection volume reached or until all injectable lesions have been treated Administration

• Inject intralesionally into cutaneous, subcutaneous, or

nodal lesions that are visible, palpable, or detectable by ultrasound guidance • Inject evenly and completely within lesion by pulling needle back without exiting lesion, redirecting needle as many times as necessary while injecting complete dose ——Inject along multiple tracks as far as the radial reach of the needle allows within the lesion to achieve even and complete dispersion ——Multiple insertion points may be used if a lesion is larger than the radial reach of the needle ——Withdraw needle from lesion slowly to avoid leakage ——Total injection volume per treatment session should not exceed 4 mL for all lesions combined — injecting all lesions at each treatment or over the full course of treatment may not be possible ——Previously injected and/or uninjected lesion(s) may be injected at subsequent treatment visits ——When lesions are clustered together, inject them as a single lesion ——Continue treatment for at least 6 months unless other treatments are needed or until there are no injectable lesions to treat Dose Adjustments

• Injection volume based on lesion size ——>5 cm: up to 4 mL ——>2.5 cm to 5 cm: up to 2 mL ——>1.5 cm to 2.5 cm: up to 1 mL ——>0.5 cm to 1.5 cm: up to 0.5 mL ——≤0.5cm: up to 0.1 mL Continues on page 36

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 35

STAT CONSULT Specific Populations

• Pregnancy ——Do not administer • Nursing mothers ——Unknown ——Decision should be made whether to discontinue nursing or discontinue therapy • Patients of reproductive potential ——No nonclinical or clinical studies have been performed to evaluate the therapy’s effect on fertility • Pediatric ——Safety and efficacy not established • Geriatric ——No overall differences in safety or efficacy between patients 65 and older vs younger • Renal impairment ——No clinical studies have been conducted to evaluate the effect of renal impairment • Hepatic impairment ——No clinical studies have been conducted to evaluate the effect of hepatic impairment Boxed Warnings

• None Contraindications

• Immunocompromised patients • Pregnant patients Cautions

• Accidental exposure ——May lead to transmission of talimogene laherparepvec and herpetic infection ——Avoid direct contact with injected lesions, dressings, or body fluids of treated patients ——Wear protective gloves ——In case of accidental exposure, clean the affected area thoroughly with soap and water and/or disinfectant • Herpetic infection ——Follow standard hygienic practices to prevent viral transmission ——Patients with suspected herpetic infections should inform their doctor ——Acyclovir or other antiviral agents may interfere with therapy • Immune-mediated events ——Glomerulonephritis, pneumonitis, vasculitis, vitiligo, worsening psoriasis, and other immune-mediated events have been reported

——Consider risks and benefits before continuing treatment in patients who develop or have underlying autoimmune disease • Injection site complications ——Cellulitis, impaired wound healing, necrosis or ulceration, and systemic bacterial infections may occur during treatment ——If persistent infection or delayed healing of injection site occurs, consider risks and benefits before continuing treatment • Obstructive airway disorder ——Use caution when injecting lesions that are close to major airways • Plasmacytoma at the injection site ——Consider risks and benefits before continuing treatment in patients with multiple myeloma or in whom plasmacytoma develops during treatment Adverse Effects

• Most common adverse reactions are (≥25% of patients) ——Chills ——Fatigue ——Influenza-like illness ——Injection site pain ——Nausea ——Pyrexia Drug Interactions

• Antiherpetic viral agents ——Acyclovir and other antiherpetic viral agents may interfere with therapeutic efficacy ——No drug interaction studies have been performed What to Tell Your Patient

• Talimogene laherparepvec is a type of anticancer medication used to treat a type of skin cancer called melanoma • It is a weakened form of the herpes simplex virus type 1, which is the virus that causes cold sores • This treatment may not help you live longer, and may not shrink cancer in your organs • Avoid talimogene laherparepvec therapy if you are pregnant or have a weakened immune system (eg, immune deficiency, blood or bone marrow cancer, steroid use, HIV/AIDS) • Your doctor will inject talimogene laherparepvec directly into your tumor • Treatment will be repeated in 3 weeks, then every 2 weeks thereafter as long as you have tumors • Treatment may continue for 6 months or longer

36 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

• Tell your doctor and nurse if you — Are taking steroids or medicines that suppress your immune system — Are taking antiviral medicines for herpes (eg, acyclovir) — Have, or ever had ■ Autoimmune disease ■ Blood or bone marrow cancer ■ HIV/AIDS ■ Other conditions that can weaken your immune system — Have close contact with someone with a weakened immune system or is pregnant • If you are or plan to become pregnant — No adequate or well-controlled studies have been conducted in pregnant women; however, — Women of childbearing potential are advised to use an effective method of contraception to prevent pregnancy during treatment. • If you are a nursing mother — No information regarding the presence of talimogene laherparepvec in human milk is available — Because medicinal products can be found in human milk, a decision should be made whether to discontinue nursing or to discontinue treatment while nursing. • Avoid spreading talimogene laherparepvec to other areas of your body or to your close contacts — Avoid direct contact with treatment sites, dressings,

or body fluids, and close contacts (use contraception, avoid kissing with open mouth sores) — Wear gloves when applying or changing dressings — Keep treatment sites covered with airtight/watertight dressings for at least 1 week posttreatment — Replace dressing with a clean dressing if comes loose or falls off; place all used dressing materials in a sealed plastic bag and throw away — Do not touch or scratch treatment sites • The most common side effects include — Chills — Fever — Flu-like symptoms — Nausea — Pain at the treatment site — Tiredness • Tell your doctor or nurse right away if you develop any signs or symptoms of herpes infections — Eye discharge or pain, light sensitivity, blurry vision — Feel extremely sleepy — Mental confusion — Pain, burning, or tingling in a blister around the mouth, genitals, fingers, or ears — Weakness in arms of legs Prepared by James Nam, PharmD.

A Mnemonic for Melanoma: Teaching Patients to Spot a Suspect Lesion The US Preventive Services Task Force concludes that current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults (see “How Effective Are Skin Screening Programs” on page 26). However, patients should be aware of the characteristics of a suspicious spot or mole and know the A-B-C-D-Es of skin lesions1,2:

Asymmetrical Does it have an irregular shape?

Border

Is the border irregular or jagged?

Color

Is the color uneven?

Diameter

Is it larger than the size of a pea?

Evolving

Has it changed during the past few weeks or months?

References 1. Final recommendation statement skin cancer: screening. US Preventive Services Task Force website. https://www.uspreventiveservicestaskforce.org/Page/Document/ RecommendationStatementFinal/skin-cancer-screening2. Accessed October 1, 2018. 2. What are the symptoms of skin cancer? Centers for Disease Control and Prevention website. https://www.cdc.gov/cancer/skin/basic_info/symptoms.htm. Accessed October 1, 2018.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 37

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RADIATION & YOUR PATIENT

Human metastatic melanoma cells (magnification 320×)

RT Abscopal Effects: A Boost for Immune Therapy? Bryant Furlow

adiotherapists have noted rare cases of antitumor effects outside of localized irradiated treatment fields — the so-called abscopal effect.1 Radiation-induced abscopal effects were long dismissed as anecdotal curiosities that occur too infrequently to be developed as a potential treatment strategy.1,2 But recent fi ndings suggest that radiation abscopal effects are mediated by patients’ immune systems. If true, then combined radiation and immune therapy regimens might leverage interactions between the 2 modalities, with radiotherapy helping to overcome tumor immune evasion to improve treatment efficacy.1 Progress is being made in the development of radioimmunotherapy strategies that can do just that, particularly in the management of advanced and metastatic melanoma.3-7 If these regimens improve treatment outcomes in large, well-designed prospective clinical trials, they will usher in a new era in radiotherapy, and with it, a new and unfamiliar constellation of treatment toxicities and patient-management challenges. IS THIS EFFECT IMMUNOLOGICAL?

For decades radiation oncology clinicians have noted rare instances of abscopal effects, in which tumors outside of a localized irradiated treatment field appear to respond to treatment. Counterintuitively, radiotherapy appears to stimulate some facets of the immune system, and recent research implicates patients’ immune cells in radiation abscopal effects — raising the possibility that combining radiotherapy (RT) and immunotherapy could yield previously untapped treatment synergies to improve tumor control. This research is advancing, most notably in the treatment of metastatic melanoma.

Localized adjuvant radiotherapy is used as a component of curative-intent treatment: irradiating the unresected margins around surgically excised tumors to kill residual microscopic tumor cell populations or to slow tumor progression as palliative therapy. Ionizing radiation is cytotoxic; it kills tumor cells via oxidative stress and damage to DNA, which can either halt cellular division or induce apoptosis. Preclinical research has shown that ionizing radiation improves immune T-cell vigilance against tumors.1,3,4 Separately, preclinical findings among

researchers who were developing immune checkpoint blockade and other immunotherapies also suggested that radiation enhanced antitumor immunity.1,3,8-10 As immunotherapies were tested clinically, cases of radiation abscopal effects were reported among patients who had received immunotherapy for advanced melanoma.4,11,12 A retrospective study of 98 patients with non-small-cell lung cancer (NSCLC) enrolled in a clinical trial of pembrolizumab immunotherapy found that those who had previously received radiotherapy saw longer progressionfree survival than those who had not undergone radiotherapy.13 One hypothesis is that radiation abscopal effects result from the creation of in situ anticancer vaccines from irradiated tumor cells, with destroyed malignant cells’ neoantigens being freed as cells break up, making them more apparent to the immune system.1-3 If that is the case, combining radiation and immunotherapy could have considerable potential for treating early-stage cancers by increasing antitumor immunity before progression and metastasis.1 MELANOMA AND RADIOIMMUNOTHERAPY

Immune checkpoint blockade immunotherapy is rapidly changing the standard of care for advanced melanoma and lung cancer. The PD-1/PD-L1 and CTLA-4 immune checkpoint pathways protect against autoimmune disease, ensuring that immune cells do not attack “self ” cells or tissues, but tumors can sometimes co-opt these signaling pathways to evade immune attack. Immune checkpoint blockade disrupts this evasion technique to facilitate T-cell-mediated antitumor immunity. These immunotherapeutic

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 39

RADIATION & YOUR PATIENT agents were pioneered in the treatment of melanoma.3,4,6,7 Authors of a recent systematic review of 16 clinical trials reporting abscopal effects among a total of 451 patients who underwent both ipilimumab CLTA-4-targeting immune checkpoint blockade and radiotherapy for metastatic melanoma reported increased abscopal response rates and improved overall survival without

Ionizing radiation improves immune T-cell vigilance against tumors. increased toxicities.4 They called for prospective randomized, controlled clinical trials to confirm the link.4 The median reported abscopal effect was 26.5% and toxicity rates for grade 3 or higher adverse events ranged from 10% to 20% (median 18%) in both study treatment and control groups.4 The most frequent toxicities associated with ipilimumab monotherapy and radioimmunotherapy alike were immune-mediated colitis, skin and mucosal toxicity, and diarrhea.4 A retrospective database records review at the Washington University School of Medicine similarly found improved overall survival among patients with metastatic melanoma brain tumors who had undergone im munotherapy plus stereotactic brain radiosurgery (median 11.1 months vs 6.2 months for patients undergoing radiosurgery without immunotherapy).6 The same research team separately reported that among patients treated for extracranial metastatic melanoma, those receiving radiotherapy in addition to immunotherapy experienced

significantly shorter overall survival (median OS 15.4 vs 19.4; P =.02).7 However, this was very likely an artifact caused by the inclusion of patients with bone metastases in the radiotherapy group; in a subsequent multivariate analysis, only patients undergoing bone radiotherapy experienced worse outcomes.7 The timing and sequencing of radiotherapy and immunotherapy also mattered, the study suggested. Patients who received radiotherapy at least 30 days prior to immunotherapy for softtissue melanoma metastases experienced longer overall survival times than those treated within 30 days of immunotherapy initiation or postimmunotherapy radiotherapy (26.1 vs 16.0 vs 15.4 months; P <.01).7 “The site and timing of radiotherapy may have important interaction with immunotherapy and need to be carefully considered in future clinical trials,” the authors cautioned.7 ■

systematic review. Clin Transl Radiat Oncol. 2018;9:5-11. 5. Franceschini D, Franzese C, Navarria P, et al. Radiotherapy and immunotherapy: can this combination change the prognosis of patients with melanoma brain metastases? Cancer Treat Rev. 2016;50:1-8. 6. Gabani P, Fischer-Valuck BW, Johanns TM, et al. Stereotactic radiosurgery and immunotherapy in melanoma brain metastasis: patterns of care and treatment outcomes [published online June 27, 2018]. Radiother Oncol. doi: 10.1016/ j.radonc.2018.06.017 7. Gabani P, Robinson CG, Ansstas G, Johanns TM, Huang J. Use of extracranial radiation therapy in metastatic melanoma patients receiving immunotherapy. Radiother Oncol. 2018;127(2):310-317. 8. Demaria S, Kawashima N, Yang AM, et al. Immune-mediated inhibition of metastasis after treatment with local radiation and CTLA-4 blockade in a mouse model of breast cancer. Clin Cancer Res. 2005;11(2):728-734. 9. Honeychurch J, Illidge TM. The influence of radiation in the context of developing com-

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

bination immunotherapies in cancer. Ther Adv Vaccines Immunother. 2017;5(6):115-122. doi: 10.1177/2051013617750561

REFERENCES 1. Rodriguez-Ruiz ME, Vanpouille-Box C, Melero I, Formenti SC, Demaria S. Immunological mechanisms responsible for radiationinduced abscopal effect. Trends Immunol. 2018;39(8):644-655. 2. Sindoni A, Minutoli F, Ascenti G, Pergolizzi S. Combination of immune checkpoint inhibi-

10. Deng L, Liang H, Burnette B, et al. Irradiation and anti-PD-L1 treatment synergistically promote antitumor immunity in mice. J Clin Invest. 2014;124(2):687-695. 11. Postow MA, Callahan MK, Barker CA, et al. Immunologic correlates of the abscopal effect in a patient with melanoma. N Engl J Med. 2012;366(10):925-931.

tors and radiotherapy: review of the litera-

12. Grimaldi AM, Simeone E, Giannarelli D, et

ture. Crit Rev Oncol Hematol. 2017;113:63-70.

al. Abscopal effects of radiotherapy on

3. Ahmed KA, Kim S, Harrison LB. Novel opportunities to use radiation therapy with immune checkpoint inhibitors for melanoma management. Surg Oncol Clin N Am. 2017;26(3):515-529. 4. Chicas-Sett R, Morales-Orue I, Rodriguez-

advanced melanoma patients who progressed after ipilimumab immunotherapy. Oncoimmunology. 2014;3:e28780. 13. Shaverdian N, Lisberg AE, Bornazyan K, et al. Previous radiotherapy and the clinical activity and toxicity of pembrolizumab

Abreu D, Lara-Jimenez P. Combining

in the treatment of non-small-cell lung

radiotherapy and ipilimumab induces clini-

cancer: a secondary analysis of the

cally relevant radiation-induced abscopal

KEYNOTE-001 phase 1 trial. Lancet Oncol.

effects in metastatic melanoma patients: a

2017;18(7):895-903.

40 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

Keep/Start/Stop Analysis Ann J. Brady, MSN, RN-BC, CHPN

disease trajectory, managing their care over time can be a challenge. Shift-to-shift RN reports are essential, yet patient “hand-off” has the potential for creating misinformation. Patient education and communication with others on the healthcare team is also essential. I wondered whether we could add Keep/ Stop/Start to our daily routines — not as a substitute for other assessment tools but as one more instrument that could be useful under certain circumstances. How might Keep/Stop/Start be incorporated into practice?

Keep what works, stop what doesn’t, start new approaches. A simple, easy-toremember way of analyzing a program.

t’s interesting when we learn something new from an unexpected source. That is exactly what happened to me recently. My niece is working on her MBA and doing a fellowship at a marketing company. She was describing a project she is working on and told me, “We are using the Change Management Model and are doing a Keep, Stop, Start analysis.” I had never heard of that concept before, yet it made perfect sense to me. Keep what works, stop what doesn’t, start new approaches. It is not a complicated system for assessing the efficacy of a program — it is a simple, easy-to-remember way of analyzing a program. And it has so many applications! I was excited ust thinking about how it could apply to nursing. All nursing is teamwork. We go into a patient’s room on our own and function with autonomy during the workday, but at some point we give our report to another nurse and go home. Continuity is always a challenge. Even when we take care of a patient over the course of several days or through their

CASE Maria went through 8 of 10 rounds of chemotherapy before she said, “No more.” Her initial response to the therapy was good — her carcinoembryonic antigen (CEA) was drastically reduced — but in short order her scans revealed tumor growth in her liver. She was offered a new treatment course and was mulling over whether or not she wanted to put herself through it. She had significant pain with her liver metastases, but said, “I’m the kind of person who never even takes an aspirin. I don’t want to take anything.” I went through my usual talk about pain medications and strategies for managing pain. I included specifics about her liver capsule pain and why I thought pain medication would help her be more functional. Her response was a thin smile and her body language clearly stated that she wasn’t buying it. I did what we all do sometimes: I assessed the situation and quickly reviewed how I was approaching her. I realized I needed to keep going with the objective information about pain management and make it understandable. I needed to stop using language that, based on her cool response,

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 41

COMMUNICATION CHALLENGES

Keep/Stop/ Start is one more tool that can help us be more effective communicators.

sounded more like I was trying to force her to do what she didn’t want to do rather than giving her the information so that she could make an informed decision. And I needed to start listening. Earlier in the conversation she had said that she liked information given to her straight up. As I adjusted my conversation with her I harkened back to that. “You told me you want me to be a straight shooter. Clearly, I’ve taken a wrong turn in my explanation. Can you tell me more about your hesitation about taking pain medications?” In this instance, the communication challenge was between me and a patient, and I was able to use Keep/ Stop/Start to help me get back on track. DISCUSSION I am fortunate to work in a Magnet hospital and one that, even before achieving Magnet status, was open to new ideas from nurses. I see patients in different hospital units, the oncology unit, the surgical unit, the intensive care unit. And because I travel throughout the hospital I encounter nurses in different settings. Perhaps because I am outside of the chain of command, a trusted other, I am often asked for my input on a variety of issues, some clinical, some job stress-related. With the support of our chief nursing officer (CNO), I have been able to put together a small pilot project aimed at mentoring. My idea is simple: support nurses in their practice, whatever that takes. Over the course of 18 months, I have gone from an ad hoc/organic process to a more formalized and developed approach. In the beginning, I had a brief explanation of what the pilot program was about, but I quickly realized this was too clunky. I kept the parts that made sense, stopped with the mundane esoteric parts, and started with wording that

seemed to fit with the adjusted nature of my “pitch.” The challenge was that I needed to make adjustments to more completely communicate my process. And I used the Keep/ Stop/Start analysis to help me to this. When I am doing rounds as part of the mentoring project, I am often asked for support/help from nurses. My role as a mentor is not to solve problems but to help nurses solve their own problems. For example, there are a few sickle cell patients who end up on our oncology unit on a regular basis with out-of-control pain. Managing pain in sickle cell patients in a pain crisis is challenging for a variety of reasons; their pain is complicated, and because of its chronic nature, their pain behaviors do not always match their pain descriptions. Each nurse approaches patient care in a different way, which in and of itself creates a layer of complexity. After being asked several times about how to approach the complex pain management of sickle cell patients, I turned it around and asked, “What do you think we should keep doing as part of their care plan? What do you think we need to stop doing? What new things could we start doing?” The communication challenge is not between patient and nurse but between nurse and nurse. Keep/Stop/Start is a framework that can be used to address that challenge. We communicate with others throughout the day and in a variety of settings, and every communication can present its own challenge. Using Keep/Stop/Start is one more tool that can help us be more effective communicators as we care for patients and interact with coworkers. ■ Ann Brady is a symptom management care coordinator at a cancer center in Pasadena, California.

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! 42 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

ISSUES IN CANCER SURVIVORSHIP

Postmastectomy Satisfaction, QOL Depend on Choice of Breast Reconstruction Bette Weinstein Kaplan

reast reconstruction is now the choice of more than 60% of breast cancer survivors who have undergone mastectomy, marking an increase of approximately 20% since 1998. A number of explanations exists for this: advances in genetic testing and imaging, continually improving reconstructive techniques, and increased media attention on celebrity patients. Recently, prominent and respected women have described their breast cancer risks, illnesses, and treatments in great detail, explaining their choices of therapeutic and/or prophylactic mastectomy and reconstruction.1 Perhaps the most significant reason for the increasing popularity of breast reconstruction is that it can lead to a better quality of life for the patient, which is essential for relieving her postmastectomy psychological distress. Therefore, a group of 57 North American plastic surgeons sought to determine which has a greater influence on the survivor’s quality of life (QOL): that she has undergone breast reconstruction per se or the type of reconstruction procedure performed. STUDY POPULATION AND TYPE OF PROCEDURE

The Mastectomy Reconstruction Outcomes Consortium study is a multicenter study designed to measure whether breast reconstruction with an

implant or an autologous procedure makes a difference in the survivor’s outlook. Eligibility criteria included age 18 years or older and undergoing first-time immediate unilateral or bilateral reconstruction for cancer treatment or prophylaxis. The prospective trial ran from February 2012 through July 2015 and comprised 2013 patients (1490 underwent implant reconstruction, 523 underwent autolo-

Type of procedure — implant vs autologous — was the primary criteria. gous tissue reconstruction). Mean age was 48 years in the implant group and 52 years in the autologous reconstruction group. All patients were followed for a minimum of 2 years. The techniques considered in this evaluation were breast reconstruction after mastectomy for cancer treatment or prophylaxis via immediate implant-based reconstruction (direct-to-implant or tissue expander and implant) or autologous reconstruction (pedicled transverse rectus abdominis myocutaneous flap, free transverse rectus abdominis myocutaneous flap, deep inferior epigastric

perforator flap, or superficial inferior epigastric artery flap). Although type of procedure — implant vs autologous — was the primary criteria, other demographic variables considered were age, race, ethnicity, body mass index, level of education, income, marital status, employment, diabetes and/or smoking status; other clinical variables included indication for mastectomy, type of procedure including whether unilateral or bilateral, adjuvant therapy (radiotherapy and/or chemotherapy), and lymph node management. USING BREAST-Q TOOL Quality of life was measured using the BREAST-Q questionnaire. This validated instrument is specific for evaluating patient reports on breast surgery outcomes and is calibrated to detect differences over time between specific procedure groups and patients.2 The researchers report that the BREAST-Q has substantially improved clinicians’ understanding of how patients regard the outcomes of their breast reconstruction procedure. Participants completed the BREAST-Q questionnaire up to 90 days prior to surgery, and at 1, 2, 3, and 4 years after surgery. Five areas of the BR EAST-Q reconstruction module were evaluated: satisfaction with breasts, sexual well-being, psychosocial well-being,

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 43

ISSUES IN CANCER SURVIVORSHIP physical well-being of the chest, and physical well-being of the abdomen. Using conversion tables, responses were converted on a scale of 0 to 100, where the higher numbers represented greater satisfaction or quality of life. TRENDS IN RESPONSE RATE Two years after their breast reconstruction, 1217 patients (60.5%) completed the BREAST-Q survey. But response rates diminished in the later years of

The researchers emphasize the importance of educating survivors about the tradeoffs. the study. At 3 years postreconstruction, 422 survivors (21.0%) completed the questionnaire, and at 4 years, 205 (10.2%) completed the questionnaire.1 Physical well-being was rated higher in the breast area 2 years after autologous reconstruction but worse in the abdominal area compared with responses from those who underwent

Lung Cancer Screening Continued from page 32

cancer in all the screening trials,” Dr Lennes said. “Furthermore, no known trials included current patients undergoing treatment for other cancers and receiving oncology nursing care.” These findings must be put into proper context because no trial has yet to demonstrate a survival benefit for patients with a previous malignancy screened for lung cancer. “The situation is complex and patients may be undergoing

implant reconstruction. Survivors who had undergone autologous reconstruction reported a high level of satisfaction with their breasts and with their quality of life, as demonstrated by their psychosocial, physical, and sexual well-being scores. However, abdominal well-being scores in this group worsened during the acute postoperative period from baseline to 1 year and did not return to that level even 2 years after breast reconstruction. By contrast, the women who underwent implant-based reconstruction were initially satisfied with their breasts and their sexual well-being, but a decrease in scores indicated their satisfaction gradually deteriorated over time.1 BREAST-Q scoring demonstrated that patients who underwent autologous reconstruction reported significantly greater satisfaction with their breasts (BREAST-Q score difference, 7.94), sexual well-being (difference, 5.53), and psychosocial well-being (difference, 3.23) at 2 years compared with those who underwent implant reconstruction.1

tradeoffs involved when choosing type of breast reconstruction to undergo. “These findings can inform patients and their clinicians about expected satisfaction and quality of life outcomes of autologous vs implant-based procedures and further support the adoption of shared decision making in clinical practice.”1 However, the researchers stress that over the long term, and irrespective of the type of reconstruction procedure, all patient responses exhibited improvement in psychosocial well-being compared with their preoperative scores. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term PatientReported Outcomes in Postmastectomy Breast Reconstruction [published online June 20, 2018]. JAMA Surg. doi: 10.1001/ jamasurg.2018.1677 2. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome

TRADEOFFS

measure for breast surgery: the BREAST-

The researchers emphasize the importance of educating survivors about the

345-353.

surveillance scans for their original cancer,” Dr Lennes told Oncology Nurse Advisor. “The decision to screen should be made after careful discussion with the primary oncologist and primary care physician taking into account overall risk for a second malignancy and the surveillance plan for the original cancer.” The authors of the current study noted that few eligible ever-smokers currently undergo lung cancer screening due to a lack of knowledge about screening among clinicians. They write that research is warranted to

Q. Plast Reconstr Surg. 2009;124(2):

improve shared decision-making tools to improve lung cancer screening in those who are at highest risk. ■ John Schieszer is a medical reporter based in Seattle, Washington. REFERENCE Katki HA, Kovalchik SA, Petito LC, et al. Implications of nine risk prediction models for selecting ever-smokers for computed tomography lung cancer screening [published online May 15, 2018]. Ann Intern Med. doi: 10.7326/M17-2701

44 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

THE TOTAL PATIENT

Hypnosis: A Comparison of the Efficacy of an Intervention Across Patient Populations Bette Weinstein Kaplan

aving cancer means coping with all sorts of stressors, each of which lead to their own negative consequences. No matter what type of cancer a patient has, the stress profile is there to accompany the disease. Pain, cancer-related fatigue, chemotherapyrelated neuropathy, difficulty sleeping, anxiety, and depression — all become part of the patient’s life and take a toll on its quality. Clinicians and palliative care specialists have utilized various modalities to help patients; hypnosis is one example. It has been proven to effectively help women with breast cancer. Doctors at University Hospital of Liège in Belgium undertook a controlled study to see whether hypnosis could be equally beneficial for men with prostate cancer. PARALLEL CANCER TYPES Cancer facts are well known and sobering. Breast cancer is the most frequently diagnosed type of cancer in women and is also a leading cause of death by cancer in women. Prostate cancer is the second leading cause of death among men. However, survival rates are increasing steadily so more patients with cancer are living with its consequences. Breast and prostate cancers share some parallels. Both occur frequently, and both are gender specific: 100% of patients with prostate cancer are male, and 99% of patients with breast cancer

are female; both cancers involve sexual organs. Although prostate cancer progresses slowly and is often treated later in the course of the illness, treatments options for both cancers are analogous. For prostate cancer, options include watchful waiting, hormone therapy, radiation therapy including brachytherapy, and surgical resection. Watchful waiting is not a typical treatment option for breast cancer, but in addition to chemotherapy, the remaining options are mainstays of breast cancer treatment as well.

Could hypnosis and CBT palliation help men as effectively as they help women? The negative effects experienced by patients are also comparable. Patients with either cancer may experience poor cognition, fatigue, difficulty sleeping, loss of libido, physical dysfunction, and pain. These adverse effects can then lead to anxiety, depression, and poor quality of life, which in turn take a toll on patients’ ability to resume normal life and work once treatment is completed. Of course, some effects are disease and/or gender specific. Prostate cancer may lead to erectile dysfunction and

other male-specific sexual problems, whereas breast cancer and its treatment may result in the alteration or loss of symbols of femininity such as breasts, menstruation, and fertility. Certain palliative care interventions are effective for women with breast cancer. Hypnosis and cognitive behavioral therapy (CBT) can reduce the fatigue and distress of living with breast cancer. Because prostate and breast cancers are so analogous, the Belgian researchers undertook a longitudinal study to determine if patients with either disease would reap similar benefit from similar interventions. Specifically, could hypnosis and CBT palliation help men with prostate cancer as effectively as they help women with breast cancer? THE STUDY Eligibility criteria included a diagnosis of prostate cancer or breast cancer, treatment with surgery and/or radiotherapy; age older than 18; and able to read, write, and speak French. Due to recruitment difficulties, researchers were only able to enroll 25 men, mean age 65 years, to the prostate cancer arm. More women with breast cancer met the eligibility criteria (114 patients; mean age, 54 years). Patients with either cancer who did not meet the study criteria were delegated to the control group. Continues on page 47

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s a social worker, I have come to understand the different ways patients redef ine hope, gratitude, and spirituality after being told they have cancer. I define hope as a belief that no matter how bleak things are at the present there is still reason for optimism and a belief it will get better; that what people want can/will happen. Gratitude is being thankful for the things you have rather than focusing on your problems. It can change the way we deal with the world, promoting thoughts and behaviors that are supportive of those around us, which in turn inspires positive feelings of compassion and love offering healing for ourselves. I define spirituality as a belief that our spirit is connected to a larger power, something more powerful than ourselves that helps us overcome adversity. Patients with newly diagnosed cancer search for understanding of what their life is going to be like during treatment and after it ends. During this time, they often re-evaluate past experiences and worry about what their future might look like. I work with patients who are searching for stability — or what they once called normal — while struggling with the stress and crisis of cancer. During this journey, a new reality sets in and what was once meaningful and important in life can suddenly change. Some patients struggle harder to hang onto who they were, whereas others find peace in letting go of control and opening up to what is often called their new normal. Those who let go while remaining involved often discover new meaning in life that helps them move forward.

Defining Hope, Gratitude, and Spirituality for Patients With Cancer Sonia Pacheco, MSW, LSW, LCSW

As an oncology social worker, I help cancer patients grieve the loss of who they were. Part of that is to help them see that although cancer might define who they are now, it will eventually become just a part of their life. This has the potential to strengthen their purpose or open the door to new possibilities.

The cornerstone of my role is to remind them of the importance of hope and help them explore what it means to them. Rituals, disclosure, illness, and death are all shaped by our culture. As a multicultural social worker, I have the knowledge to help them look at spirituality, gratitude, and hope through their cultural lens and language. Multicultural people have similar ways of coping but different ways of viewing their situation. I find it fascinating to witness the many cross cultural tools people use to survive a crisis of cancer and get to the place where they can ask, “Where do I go from here?” My reward comes in helping them explore hope as a way back home. Hope, spirituality, and gratitude, however they are perceived, provide a foundation upon which patients can build steps to a new normal. I have patients focus on strengthening existing coping skills first. I help them understand the process, explaining the roles of everyone on the medical team; this is especially important for those whose primary language is not English. Most importantly, I provide a safe place for patients to confront their fears and resistance, which are often founded on old experiences with cancer or cultural connotations. Keeping in mind that this is a process for each patient, some of whom come to the realization that no matter how much we try to control our lives, uncertainty is always there. But during this process, many people find new meaning in enjoying their life with family and friends. Others find new paths or change what wasn’t working before cancer became a part of their lives.

Hope, spirituality, and gratitude, however they are perceived, are a foundation upon which patients can build steps to a new normal. 46 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com

FROM

While in treatment, patients and caregivers can become overwhelmed. Hope and spirituality can help them get through and define meaning. After treatment, gratitude helps put meaning into action. There are many different ways of coping with stress, traumatic events, and adversity. Some are destructive (alcohol, drugs) and others are productive (prayer, exercise, meditation); the former is running away from the challenge, the latter is confronting it. The former depletes your strengths; the latter builds on them through a healthy mind and body. Although productive methods tend to focus on surviving cancer and being hopeful, they can also be effective tools for letting go of negative feelings such as anger, guilt, and sadness. Studies have shown that positive actions lead to better outcomes, improved survival, and a reinvestment in the things that bring joy in life. Normalizing feelings — good and bad — helps patients deal with change.

Patients who lose their coping skills or no longer work can digress into depression and hopelessness. They find cancer has stolen their joy for life. They can lose their sense of identity, which raises concerns among family and spouses who, in turn, become frightened of what they see in their loved ones. At these times, the whole family/friend system needs help with redefining who they are and learning to discover new meaning in life. Social workers can help patients’ loved ones rely on hope and spirituality simply by becoming role models for them. I’ve discerned transition steps that can help those impacted by cancer move on with life. Exploring what they are thankful for can give them respite from the struggle and contributes to a more positive attitude. Humor, even the self-deprecating kind, is an underestimated tool. It can challenge a negative mindset and make others in the room comfortable with your cancer. Prayer

— religious or universal — can lead to a spiritual awakening. Recognizing that none of this comes easy is important to validate the uncertainty patients and caregivers are confronting. Sometimes a healthy dose of denial can go a long way to providing respite from trauma. Looking at their life from the perspective of a survivor, incorporating joyful events into their life, and taking one day at a time to enjoy life with loved ones, family, and friends is so important. It is a gift they can share with each other. Nurses, doctors, social workers, and the rest of the medical team and facility staff at treatment centers have the ability to bring patients hope, gratitude, peace, and love. All are part of spirituality, a force that recognizes us as individual human beings while keeping us connected as a community. ■

The Total Patient

Each patient received a CD with exercises to do at home. Patients in the control group received usual care only.

Furthermore, the men in the sample did not report distress, fatigue, or sleep problems, therefore, there was little room for improvement on those dimensions. Thus, although self-care and selfhypnosis can effectively improve distress, fatigue, and sleep difficulties for women with breast cancer, these interventions simply have no such effect on men with prostate cancer. ■

Continued from page 45

Each patient in the intervention group participated in six 120-minute sessions of a self-hypnosis/self-care intervention in addition to usual care. Patients with breast cancer participated in bimonthly sessions, and those with prostate cancer participated monthly. The self-hypnosis exercises and self-care techniques were developed by one of the researchers and original to the study. Self-care topics included improving self-esteem and assertiveness, knowing one’s personal needs, defining one’s boundaries, and adjusting self-expectation. At the end of each self-care session, a therapist conducted a 15-minute hypnosis exercise.

A SIGNIFICANT DIFFERENCE The women fared much better than the men. Patients with breast cancer demonstrated reduced anxiety, depression, and fatigue and improved sleep and overall health. No such effect was noted among the men with prostate cancer. Men had a tendency toward a greater need for information than for psychological help, the researchers explained. Men often believed that their cure would come with surgery, and participating in an intervention based on psychology would make them less masculine, weaker, or more vulnerable.

Sonia Pacheco is the Hispanic Outreach Program Coordinator at CancerCare.

Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE Grégoire C, Nicolas H, Bragard I, et al. Efficacy of a hypnosis-based intervention to improve well-being during cancer: a comparison between prostate and breast cancer patients. BMC Cancer. 2018;18(1):677.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2018 • ONCOLOGY NURSE ADVISOR 47

ASK A PHARMACIST

High-Dose Flu Vaccine in Elderly Receiving Chemotherapy What information is there about using the newer high-dose flu vaccine in patients with cancer? — Name withheld on request

literature supporting the high-dose flu vaccine involves patients older than 65 who were not receiving chemotherapy, currently the vaccine is recommended for use in that population. One small study of 105 patients younger than 65 compared the standard dose with the high-dose flu vaccines.3 This study found improvements in some flu antibody titers, but did not report on the number of patients who developed the flu. At this time there is not sufficient data to support routine use of the high-dose flu vaccine in patients younger than 65 who are receiving chemotherapy. The CDC recommends reserving the high-dose flu vaccine for patients aged 65 or older. Both the high-dose and regular flu vaccine injections contain inactive viral components, thus are safe to use in patients receiving chemotherapy. Take note, however, that the intranasal flu vaccine contains live, weakened virus and should not be used in patients receiving chemotherapy or who are otherwise immunocompromised. If patients have other questions about the flu vaccine, the website www.cdc. gov/flu/protect/keyfacts.htm contains helpful information and resources. ■ REFERENCES 1. DiazGranados CA, Dunning AJ, Kimmel M, et al. Efficacy of high-dose versus standard-

The high-dose f lu vaccine (Fluzone High-Dose) contains 4 times the amount of flu antigen than the regular flu vaccine. It has been shown to produce higher antibody levels than the regular flu vaccine in patients aged 65 years or older. Some studies have shown that this correlated with reduced cases of the flu (1.9% vs 1.4% of patients who received standard dose), and can reduce the risk of respiratoryrelated hospitalizations in elderly patients who are residents of long-term care facilities.1-2 Although much of the clinical

dose influenza vaccine in older adults. N Engl J Med. 2014;371(7):635-645. 2. Gravenstein S, Davidson HE, Taljaard M,

dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial. Lancet Respir Med. 2017;5(9):738-746. 3. Jamshed S, Walsh EE, Dimitroff LJ, Santelli JS, Falsey AR. Improved immunogenicity of high-dose influenza vaccine compared to standard-dose influenza vaccine in adult oncology patients younger than 65 years receiving chemotherapy: a pilot randomized clinical trial. Vaccine. 2016;34(5):630-635.

DEA DRUG TAKE BACK DAY: OCTOBER 27 The 16th biannual Drug Enforcement Agency (DEA) Prescription Drug Take Back Day is scheduled for October 27, 2018. These take-back events are hosted in many local communities and have collected 4982 tons of unused medications since they were implemented, with more than 474 tons of unused medications collected during the most recent event in April 2018. For more information or to find an event near you, visit: www. deadiversion.usdoj.gov/drug_disposal/takeback/index.html. If patients are not able to make the take-back day in October, they can search for other locations to dispose of unused medications at https://apps. deadiversion.usdoj.gov/pubdispsearch/ spring/main?execution=e1s1.

et al. Comparative effectiveness of high-

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

48 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2018 • www.OncologyNurseAdvisor.com