ONA January/February 2018

January/February 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

PAIN MANAGEMENT

FEATURE

Looking Within: Using Cultural Humility in Communications

NAVIGATOR NOTES

Intervention Eases Disparity in Female AYA Fertility Preservation

COMMUNICATION CHALLENGES

When There Are No Words

FROM CANCERCARE

Unique Support Needs of Young Adult Patients With Metastatic Cancer

RADIATION & YOUR PATIENT

Incorporating Cardiac Care in the Oncology Setting

THE TOTAL PATIENT

The Role of the Oncology Nurse in an Effective Palliative Care Family Meeting

Achieving Adequate Cancer Pain Management in the Opioid Crisis Efforts to contain the opioid epidemic are changing the game for pain management in oncology.

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

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Oncology Nurse Advisor (ISSN 2154-350X), January/February 2018, Volume 9, Number 1. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved.

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

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 7

CONTENTS 10

IN THE NEWS • Prostate Cancer Diagnosis and Treatment Choice Affect Health-Related Quality of Life • Acupuncture Effective Alternative for Managing CancerRelated Fatigue • Axillary Lymph Node Dissection Predictive for Lymphedema • 4R+3Dex Regimen Led to Durable CR in Pediatric Chronic ITP • Fall and Fracture Risk Higher in Elderly Cancer Patients • Risk of Aging-Related Morbidities Higher for Thyroid Cancer Survivors • Breast Implants Associated With Increased Risk of Breast-ALCL • FDA Issues Warning for Rolapitant Injectable Emulsion

17

ONCOLOGY NURSE ADVISOR FORUM • Bacteria in Probiotics Carry Potential Risks for Immunocompromised Patients • Common Oncologic Emergencies That Occur in Patients With Multiple Myeloma

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41

44

49 FIND US ON

JANUARY/FEBRUARY 2018

18

NAVIGATOR NOTES Intervention Eases Disparity in Female AYA Fertility Preservation Tiffany Garbutt, PhD

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NAVIGATOR NOTES Saving Their Future: Fertility Preservation for Male AYAs

A review of the options for male patients and the significance of including a discussion of them as part of treatment planning.

Tiffany Garbutt, PhD

JOURNAL REVIEW Internet-based Learning Interventions Improve Counseling

FEATURES 24 The Opioid Epidemic Response and Cancer Pain Management Leah Lawrence

28

Researchers evaluated the effectiveness of online learning modules on physical activity counseling for oncology nurses.

John Schieszer, MA

Looking Within: Using Cultural Humility in Communications Eucharia Borden, MSW, LCSW, OSW-C

Nurses Must Be Experienced, Feel Competent When Providing End-of-Life Care

35

STAT CONSULT Ruxolitinib ( Jakafi)

39

RADIATION & YOUR PATIENT Incorporating Cardiac Care in the Oncology Setting

An analysis of select responses to a survey conducted by researchers from the College of Nursing at South Dakota State University identified oncology nurses’ comfort level in handling end-of-life care and patient education.

Bryant Furlow

John Schieszer, MA

ISSUES IN CANCER SURVIVORSHIP 41

COMMUNICATION CHALLENGES When There Are No Words Ann J. Brady, MSN, RN-BC

44

THE TOTAL PATIENT The Role of the Oncology Nurse in an Effective Palliative Care Family Meeting Bette Weinstein Kaplan

46

FROM CANCERCARE Supporting Young Adult Patients With Metastatic Cancer

Bridging the Gap in Genetic Cancer Research Data on Minority Populations

Investigators sought to determine why so few biospecimens were available for research from minority populations of women with breast cancer.

Bette Weinstein Kaplan

Colorectal Cancer and Dietary Fiber: Source Is More Important Than Amount

New research on high-fiber diets identified which types of fiber provided greater benefit.

Bette Weinstein Kaplan

Sarah Paul, LCSW

49

ASK A PHARMACIST Effective Management of Vaginal Dryness; Safe Drug Disposal Lisa A. Thompson, PharmD, BCOP

ON THE

WEB

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 9

IN THE NEWS Prostate Cancer Diagnosis and Treatment Choice Affect Health-Related Quality of Life Patients with newly diagnosed prostate cancer (PCa) who participate in the treatment planning process experience a reduction in health-related quality of life (HRQOL), particularly if they decide to pursue curative therapy.

Negative HRQOL outcomes related to prostate cancer treatment are well documented; patients experience a variety of physical and psychological adverse events after undergoing curative therapy (eg, surgery and radiotherapy) and active surveillance. However, the impact of prostate cancer on the HRQOL of patients prior to receiving treatment is unclear.

For this study, researchers assessed the results of 377 patients who completed questionnaires evaluating HRQOL (EORTC QLQ-C30 and -PR25), self-efficacy (Decision Self-Efficacy scale), optimism (LOT-r), and personality traits (BFI-10) prior to undergoing biopsy to confirm a diagnosis of prostate cancer (baseline, t0).

Of the 377 patients in the study, 126 patients whose biopsies were positive for prostate cancer completed a follow-up survey regarding HRQOL 2 weeks after selecting a course of treatment but before initiation of chosen treatment (t1).

No differences were seen in HRQOL in patients with prostate cancer vs those without the disease at t0, but patients with a positive diagnosis who made their treatment decision began to experience worse role and cognitive functioning (fatigue, urinary, bowel, constipation, hormonal) by t1. Sexual dysfunction and activity improved upon choosing treatment.

At t0, symptoms and functioning were not found to be associated with treatment decisions, but patients with prostate cancer experienced a greater deterioration of functioning and more symptoms if they decided to undergo curative treatment compared with those who opted for active surveillance at t1.

Patients who had had high scores on the LOT-r assessment had better HRQOL at baseline, whereas patients who had high marks on the Decision Self-Efficacy scale had better HRQOL at follow-up.

The authors concluded, “[d]uring clinical counseling, managing optimism when PCa is suspected (before and after biopsy) and (decisional) self-efficacy when PCa is confirmed could help to reduce the pretreatment impact on HRQoL.”

Acupuncture Effective Alternative for Managing Cancer-Related Fatigue Acupuncture was effective in managing cancer-related fatigue (CRF) in patients with cancer, according to a published study.

Cancer-related fatigue is common, with more than 50% of patients reporting the adverse effect as they progress through the disease process. Both patients and caregivers report that

CRF has a negative impact on quality of life (QOL) and more therapeutic alternatives are needed for managing it.

For this retrospective study, researchers evaluated the results of 10 clinical studies that enrolled a total of 1327 patients with cancer; 733 received acupuncture, and 594 were assigned to a control group that received sham acupuncture, typical care, or American ginseng.

Patients who received acupuncture in 20 to 30 minute sessions 3 times a week for 2 or 3 weeks, twice weekly for 2

10 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

© PHANIE / SCIENCE SOURCE

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

weeks then once a week for 6 weeks, or once a week for 6 weeks experienced substantial benefit. Few manageable adverse events were reported, including spot bleeding and bruising.

Read more at http://bit.ly/2DgV32e.

Axillary Lymph Node Dissection Predictive for Lymphedema Breast cancer treatment commonly results in lymphedema — a collection of fluid that causes swelling — in the arms and leads to limitations of daily activity as well as emotional distress and limited work ability. Although the prevalence of lymphedema is well documented among patients after the completion of adjuvant therapy with docetaxel, doxorubicin, and cyclophosphamide (TAC), data regarding the incidence of lymphedema during TAC and its effect on daily life are lacking.

For this prospective study, investigators analyzed the results of 74 patients with stage I-III breast cancer scheduled to receive TAC after surgery with or without radiotherapy.

Changes in volume were assessed with tape measurements, and lymphedema was defined as a volume difference greater than 10%. Outcomes were measured at baseline prior to cycle 1 (T0), during chemotherapy prior to cycle 2 (T1) and cycle 4 (T2), and 1 month after cycle 6 (T3). Patients received the Lymph-International Classification of Functioning (ICF) questionnaire 3 months after completing treatment.

A total of 48 patients completed all measurements. Patients did not experience any change in volume during TAC treatment, but 25% (12) of patients reported significant posttreatment volume increases at T3 compared with T0 to T2 (2.3% to 5.1%). Axillary lymph node dissection was the only predictive factor significantly associated with lymphedema (effect size, 2.9%). Results of the Lymph-ICF also revealed significant impairments at T3 compared with T0 to T2.

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

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4R+3Dex Regimen Led to Durable CR in Pediatric Chronic ITP Female adolescent patients with a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP) made less than 2 years prior may experience durable, unmaintained remission after treatment with 4 infusions of rituximab and 3 four-day cycles of dexamethasone (4R+3Dex).

Immunomodulation is the most commonly utilized therapeutic approach for patients with ITP initially, but there is a need for additional treatment methods for persistent disease. Previous studies have demonstrated that rituximab plus dexamethasone may lead to superior immediate and long-term outcomes.

For this study, researchers treated 33 pediatric patients with persistent/chronic ITP with 4R+3Dex. Eligible study patients had failed at least 1 previous therapy. The average age of nonresponders to treatment was 7.75 years, and the average of patients who displayed an initial treatment response was 12.69 years, regardless of sex.

Of the 15 patients who initially responded to treatment, 40% relapsed within the 5-year follow-up. Of the initial responders, 2 patients achieved a partial response and 13 patients achieved a complete response (CR). Patients had similar initial response rates regardless of sex, but of the 10 patients who maintained CR only 2 were males; 8 were females whose ITP was diagnosed less than 24 months prior to treatment.

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

Fall and Fracture Risk Higher in Elderly Cancer Patients Researchers assessed outcomes for 304 patients with various cancers.

The patients were older than 65 years and had undergone a geriatric assessment at baseline. The assessment measured factors such as frailty, cognitive impairment, and malnutrition; all Risk in elderly is are factors that may contribute to an 2.8 times greater increased risk of falling and fractures.

Bone density assessment was ordered for all patients but was completed in only 199 patients.

Of the patients who completed the bone density testing, approximately 80% were found to have osteoporosis or osteopenia, and prevalence of osteoporosis was higher in patients with cancer (40%) compared with patients who did not have cancer (16%). Nearly 50% of tested patients had insufficient vitamin D. Over the 2-year duration of the study researchers observed a rate of 110 fractures per 1000 person-years among elderly patients with cancer, which was 2.8 times greater than the rate among patients without cancer.

Continues on page 16

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 11

IN THE NEWS

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

Risk of Aging-Related Morbidities Higher for Thyroid Cancer Survivors Survivors of thyroid cancer have a higher risk of developing age-associated diseases compared with patients who never had cancer, particularly if they were younger than 40 years at the time of diagnosis.

For this study, researchers identiYounger survivors fied 3706 survivors of thyroid cancer have higher risk diagnosed between 1997 and 2012 and matched them to up to 5 persons based on age, sex, and birth state from a pool of 15,587 cancer-free persons.

Approximately 37% of survivors’ disease was diagnosed when they were younger than 40 years.

Compared with patients who were cancer-free, risk for developing multiple circulatory conditions 1 to 5 years after diagnosis was higher for thyroid cancer survivors. Risk for developing hypertension, cardiomyopathy, and nutritional deficiencies was higher among younger survivors.

Read more at http://bit.ly/2DGc2YK.

Breast Implants Associated With Increased Risk of Breast-ALCL Despite their widespread use, the safety of breast implants has not been confirmed. Previous studies have presented conflicting data regarding the risk of various adverse events such as breast cancer, autoimmune disease, connective tissue disease, and anaplastic large-cell lymphoma in the breast (breast-ALCL).

For this case-control study, researchers accessed the Nationwide Network and Registry of Histo- and Cytopathology in the Netherlands (PALGA) and identified 782 patients with non-Hodgkin lymphoma of the breast, which was then further narrowed to 43 women with primary breast-ALCL. Of the 43 women with breast-ALCL, 32 also had ipsilateral breast implants, compared with just 1 among 146 patients with other primary breast lymphomas.

The type of breast implant was known in 28 cases. Although macrotextured breast implants accounted for only 45% of all sales, 82% (23) of patients with breast-ALCL received this type of implant. The estimated incidence of breast implants among women aged 20 to 70 years was 3.3%.

Further analysis revealed that the cumulative risks of breast-ALCL among women with breast implants were 29 per million at 50 years and 82 per million at 70 years.

Study results showed that 6920 women with implants would increase the cases of breast-ALCL by 1 before age 75 years.

Read more at http://bit.ly/2mOLn4Q.

FDA Issues Warning for Rolapitant Injectable Emulsion Postmarketing reports have prompted the US Food and Drug Administration (FDA) to issue a warning for rolapitant (Varubi). The FDA warns that patients receiving rolapitant, a substance P/neurokinin (NK-1) receptor antagonist indicated for the prevention of delayed-phase chemotherapy-induced nausea and vomiting (CINV), may experience anaphylaxis, anaphylactic shock, or other serious hypersensitivity reaction, possibly requiring hospitalization. A Health Care Provider Letter was issued regarding these findings.

The hypersensitivity reactions occurred during or soon after infusion of rolapitant injectable emulsion, with most reactions occurring within the first few minutes of administration. Symptoms included wheezing or difficulty breathing; swelling of the face or throat; hives or flushing; itching; abdominal cramping, abdominal pain, or vomiting; back pain or chest pain; hypotension; or shock.

Appropriate treatment should be available for immediate use in the event of an anaphylactic reaction during treatment.

If anaphylaxis or any other serious hypersensitivity/infusion reaction occurs, clinicians should immediately stop the infusion; initiate appropriate medical management, including epinephrine and/or antihistamines; and permanently discontinue use of rolapitant injectable emulsion.

Clinicians and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program. Forms for Reporting to FDA can be downloaded from the website, completed, then returned to the address on the form or faxed to 1-800-FDA-0178.

Read more at http://bit.ly/2Bc7Xc0.

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Risk factors that were identified for reduced bone mass or osteoporosis were advanced age, malnutrition, and frailty, and risk factors for fractures were advanced age and frailty.

ONCOLOGY NURSE ADVISOR FORUM QUESTIONS & ANSWERS

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

Jiajoyce R. Conway, DNP, FNP-C, AOCNP, NP-C, 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.

BACTERIA IN PROBIOTICS CARRY POTENTIAL RISKS FOR IMMUNOCOMPROMISED PATIENTS Should patients receiving chemotherapy take probiotics? — Name withheld upon request Probiotics are frequently used by people with and without cancer, typically to aid in digestive issues. These products contain multiple organisms, including the bacteria Lactobacillus, Streptococcus, Bifidobacterium, and the yeast Saccharomyces.

There are some reports of patients developing infections after taking probiotics.

Some of the patients in these reports were immunocompromised, including patients who were critically ill, had HIV/AIDS, or had previously undergone organ transplantation. Due to these reports, there is some concern that patients who are immunocompromised as a result of receiving chemotherapy may also be at risk of complications due to probiotic use.

At many institutions, patients receiving immunosuppressive chemotherapy are counseled to avoid probiotics during periods of myelosuppression. In addition, patients receiving chemotherapy or who have central venous catheters are advised to avoid the use of probiotics containing certain species of Saccharomyces. This recommendation is due to multiple reports of infections in patients taking probiotics with these ingredients.

— Lisa A. Thompson, PharmD, BCOP

COMMON ONCOLOGIC EMERGENCIES THAT OCCUR IN PATIENTS WITH MULTIPLE MYELOMA What are the common oncologic emergencies seen in patients with multiple myeloma? — Name withheld on request Multiple myeloma is a plasma cell neoplasm is characterized by malignant transformation and clonal expansion of mature plasma cells, which results in overproduction of monoclonal proteins. Treatment goals are centered on detection of progressive disease and adverse events.1 Oncologic emergencies that may arise due to adverse events include myelosuppression, with anemia being the most common (97%); hypercalcemia; spinal cord compression; and acute renal failure.

Goals of care in this patient population should focus on prevention and progression of these end-organ processes. — Jiajoyce R. Conway, DNP, CRNP, AOCNP REFERENCE 1. Becze E. Manage oncologic emergencies with multiple myeloma. ONS Voice. https://voice. ons.org/news-and-views/manage-oncologic-emergencies-with-multiple-myeloma.

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

Published November 7, 2017. Accessed January 3, 2018.

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

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C

hemotherapy and radiotherapy may cause fertility loss, which may be particularly devastating for adolescents and young adults (AYAs). For some AYA patients with cancer the possibility of infertility may be more devastating than the cancer diagnosis itself.1 AYA patients may experience distress and regret if not given the opportunity to discuss the risk of treatment on fertility and possible fertility preservation options.2 Preserving fertility means preserving the hope of a future. Having discussions about fertility preservation may be important to enhancing the later quality of life for young cancer survivors. Yet, AYA patients are less likely to receive information about fertility preservation. Female AYA patients, in particular, are less likely than their male counterparts to receive information about fertility preservation.3 A recently published study found that bundled interventions may help to close the fertility-information gender gap between male and female AYA patients.4 The study looked at the effectiveness of bundled interventions across five Youth Cancer Service Centers in Queensland, Australia. Bundled interventions were introduced in the centers in 2015 and included 4 components: quality indicators, targeted education, patient resources, and referral processes.

Quality indicators were reported by providers in a web-based system and included information on if the patient was provided with both written and verbal fertility preservation options, if the patient was referred to a specialist, if

Intervention Eases Disparity in Female AYA Fertility Preservation Tiffany Garbutt, PhD

the patient ultimately underwent fertility preservation, and if so, which method.

Targeted information sessions for more than 80 healthcare professionals were held and included topics on fertility and genetics; communicating with AYAs; sexuality, intimacy, and relationships; and fertility preservation

methods for males and females. The sessions included a 30-minute presentation in which healthcare professionals were provided with a fact sheet; resources including journal articles, websites, and a printout of the presentation; and a discussion of referral pathways.

A learning needs survey taken in 2013 by 107 healthcare professionals across all sites indicated that while clinicians were aware of a variety of resources, not having a list of these resources readily available to give to the patient prevented some clinicians from having fertility discussions. Therefore, as part of the bundled intervention, resource packs with gender-specific information and brochures for fertility specialist groups were provided to patients by cancer care coordinators.

Lastly, referral pathways, procedures, and work instruction forms were developed. In the past, referral to fertility experts was informal and consisted only of a phone call, which resulted in a lack of shared information between the specialist and the physician. Having a formalized process of referral streamlined the process.

The researchers compared the prebundling cohort to the postbundling cohort and found that the postbundling cohort was more likely to have a documented discussion about infertility risk and was more likely to be referred to a fertility specialist, resulting in improved fertility preservation outcomes. Notably, while the researchers found that documented fertility discussions increased postbundling in both genders, the greatest improvement was with female patients. However, males were still more

Bundled interventions may help to close the gender gap between male and female AYA patients receiving fertility information.

18 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

Š MEDIA FOR MEDICAL / JEAN-PAUL CHASSENET / MEDICAL IMAGES

NAVIGATOR NOTES

significantly likely to be referred to a fertility specialist than females.

The authors suspect that one reason for the gender disparity is that preserving female fertility is more technically difficult than preserving male fertility.

Male fertility preservation is relatively quick and noninvasive. In contrast, the only nonexperimental method of female fertility preservation is oocyte collection and cryopreservation, which can be a month-long invasive procedure where the young woman is given fertility drugs to stimulate egg production. The eggs are then collected using multiple vaginal ultrasounds and vaginal egg retrieval, which may make some families and patients uncomfortable. In addition, a delay in cancer treatment may not be possible for all patients and relatively few oocytes actually survive the cryopreservation and thawing process.5 One alternative is ovarian tissue freezing, which although it is still considered experimental has resulted in the birth of at least 70 healthy babies.6 During the outpatient procedure, one ovary is surgically removed and the outer surface that contains the immature egg follicles is frozen in strips. These strips can be transplanted back into the woman at a later date when she is cancer free. The hope is that the immature follicles will begin to develop as they would in a normal ovary. The fi rst live human birth from this procedure was reported in 2004.7 However, the success of this procedure has largely been with tissue frozen after puberty. The first case of successful pregnancy and birth following ovarian tissue frozen before

FIND US ON

puberty was recently reported and demonstrates the feasibility of the procedure even after 13 years of cryopreservation.

Reimplantation of cryopreserved ovarian tissue might not be possible for every patient as there may be an increased risk of reintroducing cancerous cells for some types of cancer.

Another more experimental procedure, which has not yet resulted in live human birth, is in vitro follicle matura-

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

More advances for female fertility preservation are needed.

3. Barlevy D, Wangmo T, Elger BS, Ravitsky V.

REFERENCES 1. Schover LR. Patient attitudes toward fertility preservation. Pediatr Blood Cancer.

2009;53(2):281-284.

2. Letourneau JM, Ebbel EE, Katz PP, et al.

Pretreatment fertility counseling and fertility preservation improve quality of life in reproductive age women with cancer. Cancer.

2012;118(6):1710-1717.

Attitudes, beliefs, and trends regarding adolescent oncofertility discussions: a systematic literature review. J Adolesc Young Adult Oncol.

2016;5(2):119-134.

4. Bradford NK, Walker R, Henney R, Inglis P, Chan RJ. Improvements in clinical practice for fertility preservation among young

tion, where instead if reimplanting the tissue, the immature follicles are grown to maturity in the lab. The mature egg can then be fertilized in the lab and the embryo implanted into the uterus.

Healthcare professionals may be more likely to encourage fertility preservation in males than females because current female fertility preservation options are often considered experimental with no proven benefit, and therefore not worth the delay in treatment.8 More advances for female fertility preservation are needed, so that delays in treatment are reduced and female fertility preservation is comparable to males.8 However, females should still be made aware of their available fertility preservation options. Bundling interventions such as these just might be the first and easiest step to bridging the fertility preservation gender gap. â–

cancer patients: results from bundled interventions [published online ahead of print September 21, 2017]. J Adolesc Young Adult Oncol. doi: 10.1089/jayao.2017.0042 5. Bagchi A, Woods EJ, Critser JK. Cryopreservation and vitrification: recent advances in fertility preservation technologies. Expert Rev Med Devices.

2008;5(3):359-370.

6. Silber S. Ovarian tissue cryopreservation and transplantation: scientific implications. J Assist Reprod Genet. 2016;33(12):1595-1603.

7. Donnez J, Dolmans MM, Demylle D, et al.

Live birth after orthotopic transplantation of cryopreserved ovarian tissue. Lancet.

2004;364(9443):1405-1410.

8. Barlevy D, Elger BS, Wangmo T, Ravitsky V. Adolescent oncofertility discussions: recommendations from a systematic literature review. AJOB Empir Bioeth. 2007; 8(2):106-115.

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FEATURE | Pain Management

The Opioid Epidemic Response and Cancer Pain Management Oncology nurses respond to current legislation and practice trends regarding opioid prescribing and their effect on pain management in cancer patients.

© ILLUSTRATION BY JOHN HOLCROFT

New rules are prompting oncology clinicians and cancer patients to change their pain management strategies.

LEAH LAWRENCE

T

he Centers for Disease Control and Prevention (CDC) estimates that since 1999 the number of overdose deaths involving prescription opioids has quadrupled and that approximately 91 Americans die each day from an opioid overdose.1 In response to what many are calling an opioid epidemic, the CDC issued guidelines for limiting prescribing of opioids and many state legislatures have passed or are in the process of passing laws limiting opioid prescriptions. Although much of the response to the opioid epidemic exempts treatment for cancer-related pain, a recent Oncology Nurse Advisor online survey showed that more than 80% of respondents were concerned about how current restrictions set up to manage the opioid crisis are affecting cancer patient pain management.

“What we are seeing is more and more difficulty for our patients in getting their pain medicine,” said Ann Brady, MSN, RN-BC, CHPN, a symptom management care coordinator at Cancer Center Huntington Hospital in Pasadena, California. “In the past, a physician could write an order for an opioid and the patient could fill it.

Now there are a lot more hoops to jump through.”

CANCER-RELATED PAIN The International Agency for Research on Cancer estimated that in 2012 there were more than 32 million people worldwide living with cancer, and that number is expected to increase to more than 52 million by 2030.2

24 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

As the number of people with cancer increases, so too will the number of people living with cancer-related pain. An estimated 4 in 10 cancer survivors live in some degree of pain, and 5% to 10% have severe chronic pain.3,4 Pain related to cancer is dynamic. Patients with cancer can experience pain related to the tumor itself. A tumor growing in an organ may stretch part of the organ, causing pain.

Tumors that metastasize to bone, the spinal cord, or a nerve can also cause pain. However, cancer-related pain can also be due to cancer treatment. Patients undergoing surgery, radiation therapy, chemotherapy, bone marrow transplant, or hormonal therapy can experience a variety of types and degrees of pain that may be long-lasting.5 “The management and care of cancer-related pain is quite complex and requires multiple disciplines to help cancer patients get control of their pain,” said Jiajoyce Conway, DNP, CRNP, AOCNP, an oncology nurse at Cancer Care Associates of York in York, Pennsylvania.

According to Dr Conway, opioids may be considered for cancer-related pain in several settings including short-term use in patients with pain due to treatment, and for the treatment of patients with advanced disease who are experiencing significant pain.

Unfortunately, since the recognition of and response to the growing opioid epidemic, both Dr Conway and Ms Brady have begun to face difficulties in getting their patients their pain medication.

OPIOID EPIDEMIC RESPONSE In 2016, several things happened to signal a growing recognition of the opioid epidemic in the United States. First, the Comprehensive Addiction and Recovery Act was signed into law. The legislation was a comprehensive attempt to address the opioid epidemic and authorized more than $180 million each year in funding to address 6 areas necessary for a coordinated response to the opioid epidemic: prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose reversal.

In addition, the CDC released its “Guideline for Prescribing Opioids for Chronic Pain.”6 The guideline outlined voluntary, evidence-based recommendations for prescribing opioids in patients aged 18 years or older in a primary care setting. The guideline suggested starting with the lowest effective dose possible and prescribing only what is needed for the expected duration of pain. Specifically, it noted that a prescription for 3 days or less will often be enough to manage acute pain and a prescription for more than 7 days will rarely be needed. The

CDC guideline recommendations are for the prescribing of opioid pain medications in outpatient settings outside of active cancer treatment, palliative care, and end-of-life care.

In recent years many states have also passed legislation limiting opioid prescriptions. According to the National Conference of State Legislatures, 24 states have enacted legislation limiting opioid prescribing or giving guidance related to opioid prescribing.7 Legislation in Minnesota and Kentucky limits first-time opioid prescriptions to a limit of 3 to 4 days; Hawaii, Alaska, Utah, Louisiana, Pennsylvania, New York, Massachusetts, Connecticut, Indiana, and Maine all limit first-time prescriptions to 7 days. Approximately half of the states with legislation specify that prescriptions must be for the treatment of acute pain. Similar to the CDC

Even once an opioid prescription is approved, [patients] may still run into issues when they go to a pharmacy to fill the prescription. guidelines, most of these laws exempt treatment for cancer and palliative care.

“These opioid restrictions are supposed to carve out for cancer pain, and I think technically they do, but on a practical level it does not always work that way,” Ms Brady said. “Most people’s understanding of opioids is related to the crisis and often doesn’t distinguish between cancer pain and other pain.”

Ms Brady has seen these effects in her day-to-day care for patients. For example, some insurance companies and pharmacies are responding to the opioid crisis by being more restrictive with pain medications, she said. Ms Brady will often have to call insurance companies and speak with several rounds of representatives in order to obtain insurance coverage for a patient to receive the type, strength, or length of opioid prescription necessary for their pain.

“This can be very frustrating and time consuming because sometimes we are making changes to pain management treatment on a day-to-day basis,” she said.

Dr Conway has also encountered these issues, adding that some insurance carriers will not authorize coverage beyond emergency 3-day or 7-day prescriptions.

Ms Brady has also heard from patients that even once an opioid prescription is approved by their insurance carrier, they may still run into issues when they go to a pharmacy to

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 25

FEATURE | Pain Management fill the prescription. “If a physician writes for 90 pills and the pharmacy says they only have 30 pills in stock, the patient may only get 30 pills and will not be able to come back to get the remainder of those pills,” she explained.

Opioid addiction is still a concern in patients with cancer, especially as more and more patients continue to survive beyond 10 years.

“That is inadequate pain control,” Dr Conway points out.

“This can lead to patients rationing out their pain medication, and in between pills they are suffering.”

Ms Brady said she has also heard of pharmacies requiring that opioid prescriptions be picked up in person by the patient.

“For some patients with cancer that is a huge burden.”

OPIOID ADDICTION Opioid addiction is still a concern in patients with cancer, especially as more and more patients continue to survive beyond 10 years. According to Dr Conway, that means the prescribers must carefully weigh the pros and cons of these medications.

“If I am treating a patient with advanced, terminal disease, and I know that patient is likely addicted to the medication, am I going to fight the patient knowing that their time is limited and they have no other way to survive but on pain medication? No,” Dr Conway said.

However, there are rare situations where patients with cancer or cancer survivors begin to seek opioid medications from multiple providers, and that should be recognized as drug-seeking behavior, she said.

“Although it is only a small subset of patients, these patients have to be held accountable for such behavior,” Dr Conway said. “If I have any concern that a patient is receiving opioids from multiple providers I will hold them accountable to a pain contract, and if they violate that contract we will no longer prescribe for that patient.”

nerves; antihistamines, which can help control nausea and itching; antianxiety drugs, which can treat muscle spasms; or anticonvulsants, which help control nerve pain.8 Ms Brady is also a big proponent of integrative therapy.

“The clinic where I work has an acupuncturist, a massage therapist, and someone who does classes on mindfulness, and while patients are in the hospital there is music therapy, pet therapy, and a variety of other things available,” she said.

“However, a lot of times these things may help, but will not be a complete fix.”

Dr Conway believes oncology nurses, advance practitioners, and physicians have a responsibility to provide all types of supportive services for patients with cancer experiencing pain.

“That starts with assessing patients individually and not grouping everyone into one category,” Dr Conway said.

“An individualized approach to care means understanding what type of pain they have, their goal of management, and what long-term outcomes we are seeking.” ■ Leah Lawrence is a medical writer based in West Chester, Pennsylvania.

REFERENCES 1. Understanding the Epidemic. Drug overdose deaths in the United States continue to increase in 2015. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugoverdose/epidemic/index.html.

Accessed November 29, 2017.

2. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012. International Agency for Research on Cancer World Health Organization website. http://globocan.iarc.fr/Pages/fact_sheets_ cancer.aspx. Accessed November 29, 2017.

3. van den Beuken-van Everdingen M. Chronic pain in cancer survivors: a growing issue. J Pain Palliat Care Pharmacother. 2012;26(4):385-387.

4. Glare PA, Davies PS, Finlay E, et al. Pain in cancer survivors. J Clin Oncol.

2014;32(16):1739-1747.

5. ASCO Answers Managing Cancer-Related Pain: A Guide for Patients, Families, and Caregivers. Alexandria, VA: American Society of Clinical Oncology; 2017. https://www.cancer.net/sites/cancer.net/files/managing_pain_ booklet.pdf. Accessed November 29, 2017.

6. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016; 65(No. RR-1):1-49.

NONOPIOID PAIN MANAGEMENT

Of course, there are management options for treating cancerrelated pain outside of the use of opioids. Mild to moderate pain can be controlled with the use of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Other drugs may be used in conjunction or in place of opioids to help relieve cancer-related pain. These include antidepressants, which can treat tingling or burning pain from damaged

7. Prescribing Policies: States Confront Opioid Overdose Epidemic.

National Conference of State Legislatures website. http://www.ncsl.org/ research/health/prescribing-policies-states-confront-opioid-overdoseepidemic.aspx. Accessed November 29, 2017.

8. Non-opioids and other drugs used to treat cancer pain. American Cancer Society website. https://www.cancer.org/treatment/treatmentsand-side-effects/physical-side-effects/pain/non-opioids-and-otherdrugs-to-treat-cancer-pain.html. Accessed November 29, 2017.

26 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

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FEATURE | Nurse-Patient Communications

Looking Within: Using Cultural Humility in Communications This novel approach to understanding minority cultures relies on letting patients determine how their culture defines who they are.

EUCHARIA BORDEN, MSW, LCSW, OSW-C

© SHAPECHARGE / iSTOCK

A

Humility relies on relinquishing potentially biased knowledge and relearning cultures from patients.

s seasoned healthcare professionals, we have experienced many defining moments at various points throughout our career. Although action is not always required, what we do after or as a result of those experiences can change the trajectory of our lives.

I recall one such experience many years ago.

I was sitting with members of my multidisciplinary team. We were anticipating the arrival of a patient and his family to discuss his diagnosis and treatment plan. We learned minutes before the patient entered the room that he didn’t speak English, and the only member of his family who did was his adult son. Like most healthcare settings, we have a policy in place that outlines why we use an official interpreter rather than a family member and how to make arrangements for an interpreter.

In this case, the patient was already approaching the door, so the team moved forward given that there was no time to make other arrangements.

As the team reviewed the plan of care, the son followed along quite attentively, asking clarifying questions but translating very little. You could see the patient staring at his son with a questioning look, appearing as though he was eagerly awaiting the next set of translated sentences.

After the meeting, the team discussed the fact that the son translated so little that the patient may not have a clear understanding of anything that happened during the meeting, and the fact that an interpreter must be used during future visits. We also talked about potential reasons for the lack of translation, including the assumption

28 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

that the son did not want his dad to know all of the details of his diagnosis or treatment plan for fear that knowing may hasten his death. This assumption was based on experiences with other patients of Asian descent, as well as education from cultural competency trainings and tools designed to help us understand cultural meanings in health care.

A week later, the son called and asked to meet with me.

He told me, “I was so scared.” He further explained that his dad came to the United States many years before he and his mother were able to come. By then, his dad was working days, evenings, and even many weekends to support the family. This means that they had very little interaction.

Since his dad’s cancer diagnosis, the son has been placed right in the middle of all his dad’s financial affairs, which made him quite uncomfortable. Although there was little personal interaction, the son had great respect for his dad and now also concern about the many ways in which his parents had been struggling financially without his knowledge. He also wanted to discuss his own fears and worry about his dad’s health. Not once did he say anything that confirmed the assumptions that we — that I — had made.

I came away from this meeting thinking, “What’s different in this case?” I couldn’t quite put my finger on it, but I knew immediately that I could not rely on my experiences with other patients who shared the same or similar cultural background, nor could I rely solely on the cultural competency trainings that I had received. As an oncology social worker, my role is to address psychosocial issues and concerns faced by our patients, their caregivers, and loved ones. But how could I do this effectively if I was the one defining the issues, challenges, and concerns that our patients were experiencing in health care?

WHAT IS COMPETENCY I was becoming increasingly concerned about the gaps that “cultural competency” training left in terms of learning how to actually interact with patients of minority cultures. I also didn’t like the fact that competency implies mastery over another (in this case another’s culture). The biggest problem is that when one feels competent, he or she begins to assume the role of an expert; however, at times the characteristics or traits attributed to a particular group may actually be stereotypes or personal biases.

Perspectives on cultural competence vary. E-Shien Chang, a public health researcher at Rush Institute for Healthy Aging in Chicago, and colleagues, point out that “much of the literature discusses the importance of cultural awareness, knowledge, attitudes, and skills.”1 According to Jessica Gregg, MD, PhD, and Somnath Saha, MD, MPH, of the

Oregon Health and Science University in Portland, Oregon, “the cultural competence movement … began … primarily by educating physicians and policymakers about culture, culture-specific beliefs, and their potential impact on health and health care.”2 More specifically, Mary Isaacson, RN, PhD, of South Dakota State University in Vermillion, South Dakota, offers this definition: “Cultural competence implies that the healthcare professional has an a priori understanding of the person’s culture before engaging with the patient.”3 HUMILITY VS COMPETENCY Struggling with cultural competence definitions and practice attempts, I looked for another framework to help guide my work and found cultural humility. Cultural humility focuses on us. No matter which definition one chooses, the idea of cultural competency training focuses on understanding more about others. Cultural humility is a concept that has three dimensions4:

• Lifelong learning and critical self-reflection, • Recognizing and challenging power imbalances, and • Institutional accountability.4 Cultural humility encourages developing an attitude of not knowing and learning from the patient. Whereas cultural competence training takes place at one or several finite point(s) in time, cultural humility is an ongoing active process for the healthcare provider. Tervalon and Garcia describe it this way: “Humility is a prerequisite in this process” where one “relinquishes the role of expert to the patient, becoming the

Cultural humility encourages an attitude of not knowing and learning from the patient ... an ongoing active process for the healthcare provider. student of the patient with a conviction and explicit expression of the patient’s potential to be a capable and full partner in the therapeutic alliance.”4 Chang and colleagues suggest that by following this model, we get “patient satisfaction, better medical adherence, and improved health outcomes.”1 This concept also differs from cultural competence models in that it openly addresses power imbalances among patients, providers, and institutions. It emphasizes that there must be accountability within our institutions and also within ourselves.

Continues on page 30

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 29

FEATURE | Nurse-Patient Communications A CHANGE IN THINKING When you approach a patient, do you think, “I’ve learned about them, the behavior(s) they exhibit, or this belief that they have?” If so, how do you engage patients to help you understand who they are in their own cultural context?

A Muslim immigrant may share a cultural, ethnic, and/or religious identity with a Muslim citizen who lives in West Philadelphia, but there will undoubtedly be differences in how these 2 patients have experienced Western culture and perhaps even how they’ve interacted within our health systems. At what point does either patient get the opportunity to help us understand their identity and how this factors into their own experiences with illness? At what point do we begin to realize that what we’ve learned about others can inform us, but this information is — or rather should be — meant to provide a backdrop of possibilities rather than serve as the standard to guide all interactions with everyone who fits a cultural or ethnic description? This is the key difference in practicing with cultural humility.

Fisher-Borne and colleagues offer this list of critical questions for people and organizations to assess their cultural humility5:

• “What are my initial reactions to [patients], specifically those who are culturally different from me?”

• “What social and economic barriers impact a client’s ability to receive effective care?”

• “Does our organization’s culture encourage respectful, substantive discussions about difference, oppression, and inclusion?”

• “What training and professional development opportunities do we offer that address inequalities and encourage active self-reflection about power and privilege?”

• “Does our staff reflect the communities we serve?”5 I’ve come to realize that the idea of not knowing is not comfortable for everyone. What kind of power imbalance do we unknowingly create when we act as though we already know everything about the person in front of us? Imagine a provider labeling a patient as “difficult” and describing immense tension after the patient’s visit. Blaming the patient for “difficult” interactions is sometimes easier. However, if we were to examine perceived power imbalances from the patient’s perspective, consider how the clinician’s own statements or behaviors may have added to the tension, or explore whether patients of certain backgrounds within our institutions get labeled as “difficult” more often, then we would be looking at examples such as this through a cultural humility lens.

What kind of power imbalance do we unknowingly create when we act as though we already know everything about the person in front of us?

A more practical application of the dimensions of cultural humility can assist providers in “potentially creating an atmosphere that enables and does not obstruct the patient’s telling of his or her own illness or wellness story … only the patient is uniquely qualified to help the physician understand the intersection of race, ethnicity, religion, class … in forming his (the patient’s) identity and to clarify the relevance and impact of this intersection of the present illness or wellness experience.”4 CONCLUSION As the United States becomes more of a “minority majority” nation, as described in the 2010 Census report, learning effective ways to communicate and build clinical relationships with people of diverse backgrounds is critically important.

“Learning about culture will not eliminate disparities” and “becoming culturally competent is not a panacea for health disparities.”2 We must look continually within ourselves and within our institutions at our own beliefs and practices, recognizing and challenging power imbalances, and be accountable to truly meet our patients’ needs effectively.

To learn more about cultural humility, visit the Online Learning section of the Association of Oncology Social Work website (www.aosw.org/professional-development/ online-learning/). ■ Eucharia Borden is an outpatient oncology social worker at Lankenau Medical Center in Wynnewood, Pennsylvania.

REFERENCES 1. Chang ES, Simon M, Dong X. Integrating cultural humility into health care professional education and training. Adv Health Sci Educ Theory Pract. 2012;17(2):269-278.

2. Gregg J, Saha S. Losing culture on the way to competence: the use and misuse of culture in medical education. Acad Med. 2006;81(6):542-547.

3. Isaacson M. Clarifying concepts: cultural humility or competency. J Prof Nurs. 2014;30(3):251-258 4. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117-125.

5. Fisher-Borne M, Cain JM, Martin SL. From mastery to accountability: cultural humility as an alternative to cultural competence. Soc Work Educ.

2015;34(2):165-181.

30 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

STAT CONSULT Ruxolitinib (Jakafi) Drug type

• Ruxolitinib is a Janus associated kinase ( JAK1/ JAK2) inhibitor

Indication

• Intermediate or high-risk myelofibrosis including ——Primary myelofibrosis ——Post-polycythemia vera myelofibrosis ——Post-essential thrombocythemia myelofibrosis.

• Polycythemia vera in cases of inadequate response or intolerance of hydroxyurea Mechanism of Action

• Ruxolitinib is a JAK1/JAK2 inhibitor that blocks cytokine signaling and growth factor receptors, which are important for hematopoiesis and immune function.

• JAK signaling involves the recruitment of signal transducers and activators of transcription (STATs) to cytokine receptors, activation, and localization of STATs to the cell nucleus that leads to gene expression modulation Dosage

• Myelofibrosis ——Starting dose is based on baseline platelet count ■■ >200×109/L: 20 mg orally twice daily ■■ 100×109/L to 200×109/L: 15 mg orally twice daily ■■ 50×109/L to <100×109/L: 5 mg orally twice daily • Polycythemia vera ——Starting dose: 10 mg orally twice daily Administration

• Monitor CBC before initiating therapy, every 2 to 4 weeks until doses are stabilized, and then as clinically indicated ——Doses may be titrated based on safety and efficacy ——Modify or interrupt dosing for thrombocytopenia

• Oral administration with or without food • If dose is missed, patient should not take an additional dose but wait until the next prescribed dose • Discontinuation for any reason other than thrombocytopenia should be tapered (eg, reduced by 5 mg twice daily each week) • Ruxolitinib can be administered via 8 French or greater nasogastric tube ——Suspend one tablet in approximately 40 mL of water and stir for 10 minutes ——Administer via tube with syringe within 6 hours of tablet dispersion ——Tube should be rinsed with 75 mL of water Dose Adjustments

• Myelofibrosis ——Hematologic toxicity ■■ Interrupt treatment when platelet counts go below indicated levels and absolute neutrophil count (ANC) is <0.5×109/L ■■ After recovery of platelet counts and ANC is >0.75×109/L, dosing may be restarted.

■■ Restart dosing at the higher of 5 mg once daily or 5 mg twice daily less than the largest dose in the week prior to treatment interruption »» See full prescribing information for platelet counts and dose schedules when interrupting or restarting treatment ——Insufficient response ■■ If platelet and neutrophil counts are adequate, doses may be increased in 5 mg twice daily increments

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 35

STAT CONSULT »» See full prescribing information for maximum doses ■■ Doses should not be increased during the first 4 weeks of therapy and not more frequently than every 2 weeks ■■ Discontinue ruxolitinib if there is no spleen size reduction or symptom improvement after 6 months of therapy ——Thrombocytopenia ■■ See full prescribing information for dose reduction tables • Polycythemia vera ——Hematologic parameters ■■ Interrupt treatment for hemoglobin <8 g/dL, platelet counts <50×109/L, or ANC <1.0×109/L ■■ After recovery of the hematologic parameter(s) to acceptable levels, dosing may be restarted »» See full prescribing information for dosing tables ■■ After restarting following treatment interruption, doses may be titrated, but the maximum total daily dose should not exceed 5 mg less than the dose that resulted in the dose interruption. »» Except following phlebotomy-associated anemia ——Insufficient response ■■ If platelet, hemoglobin, and neutrophil counts are adequate, doses may be increased in 5 mg twice daily increments to a maximum of 25 mg twice daily.

■■ Doses should not be increased during the first 4 weeks of therapy or more frequently than every 2 weeks.

■■ Consider dose increases for patients who meet the following criteria »» Inadequate efficacy as demonstrated by 1 or more of the following: –– Continued need for phlebotomy –– WBC greater than the ULN range –– Platelet count ≥140×109/L –– Palpable spleen is reduced by <25% from baseline »» Platelet count ≥140×109/L »» Hemoglobin ≥12 g/dL »» ANC ≥1.5×109/L ——Concomitant strong CYP3A4 inhibitors or fluconazole ■■ Modify dosage when coadministered with strong CYP3A4 inhibitors and fluconazole doses ≥200 mg ■■ Additional modifications should be made with frequent monitoring for safety and efficacy ■■ Avoid use of fluconazole doses >200 mg daily with ruxolitinib ■■ See full prescribing information for dosing table

——Renal impairment ■■ See full prescribing information for dose modifications for patients with moderate or severe renal impairment ■■ End stage renal disease (ESRD) »» Starting dose for patients with myelofibrosis on dialysis: –– Platelet count 100×109/L to 200×109/L: 15 mg once after a session –– Platelet count <200×109/L: 20 mg once after a dialysis session »» Starting dose for patients with polycythemia vera on dialysis: 10 mg »» Make additional dose modifications with frequent monitoring of safety and efficacy »» Avoid use of ruxolitinib in patients with ESRD not requiring dialysis ——Hepatic impairment ■■ See full prescribing information for dose modification table Specific Populations

• Pregnancy ——No available data in pregnant women ——May cause fetal harm based on findings in animal studies • Nursing mothers ——Discontinue breastfeeding during treatment and for 2 weeks after the final dose • Pediatric ——Safety and efficacy not established • Geriatric ——No clinically relevant differences in safety of efficacy was observed between younger and older patients • Renal impairment ——Reduce dose or avoid treatment as recommended • Hepatic impairment ——Reduce dose or avoid treatment as recommended Boxed Warnings

• None Contraindications

• None Cautions

• Anemia ——May require blood transfusions and/or dose modifications

36 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

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STAT CONSULT ——Perform baseline CBC and monitor every 2 to 4 weeks until stabilization • Lipid elevations ——Assess blood lipid levels 8 to 12 weeks after initiation ——Monitor and treat accordingly • Neutropenia ——In severe neutropenia (ANC <0.5×109/L), withhold until recovery ——Perform baseline CBC and monitor every 2 to 4 weeks until stabilization • Non-melanoma skin cancer ——Perform periodic skin examinations • Risk of infection ——Serious bacterial, mycobacterial, fungal, or viral infections may occur ——Delay treatment initiation until resolution of active infections ——Monitor for signs and symptoms of infection and manage promptly ——Reported infections include ■■ Hepatitis B, herpes zoster, progressive multifocal leukoencephalopathy, tuberculosis • Symptom exacerbation upon interruption or discontinuation ——Treatment should be tapered vs abruptly stopped ——Manage with supportive care and consider reinitiation or dose increase • Thrombocytopenia ——May require platelet transfusions. Reduce dose or temporarily suspend treatment.

——Perform baseline CBC and monitor every 2 to 4 weeks until stabilization Adverse Effects

• Most common hematologic adverse reactions (>20% of patients) ——Anemia, thrombocytopenia • Most common non-hematologic adverse reactions (>10% of patients) ——Bruising, dizziness, headache Drug Interactions

• Strong CYP3A4 inhibitors ——Increases ruxolitinib exposure, increasing risk of exposure-related toxicity. Consider dose reductions • Strong CYP3A4 inducers ——Decreases ruxolitinib exposure. No dose adjustment necessary ——Monitor patients and adjust based on efficacy and safety

• Fluconazole ——May increase ruxolitinib exposure, increasing risk of exposure-related toxicity ——Avoid use of ruxolitinib with fluconazole doses greater than 200 mg What to Tell Your Patient

• Ruxolitinib is a kinase inhibitor, a type of anticancer medication • Take ruxolitinib twice daily (approximately 12 hours apart) ——If you miss a dose, take the next usual prescribed dose • You can take this medication with or without food • If you cannot swallow the tablets, dissolve 1 tablet in approximately 40 mL of water, stirring for approximately 10 minutes.

——Take the medication through a nasogastric tube using an appropriate syringe within 6 hours after the tablet has dispersed.

• You will need to undergo regular blood tests before and during treatment with ruxolitinib.

• Your risks for certain adverse effects are higher while taking ruxolitinib. If you experience any of these symptoms, call your nurse or doctor right away.

——Abdominal pain, balance issues, bleeding, bruising, burning or pain on urination, chills and sweats, diarrhea, fever, loss of coordination, nausea, sensory loss, shortness of breath, stiff neck, vision changes, vomiting, and weakness • Ruxolitinib may increase blood cholesterol. Your cholesterol levels will be monitored while you are receiving treatment.

• Tell your oncology team all of the medications you are taking, including prescriptions, over-the-counter medicines, and any supplements you are taking.

• If you are on dialysis, you should take your dose of ruxolitinib only after your dialysis session, not before a session.

• You should discontinue breastfeeding during treatment with ruxolitinib and for 2 weeks after your final dose.

• This is a long-term treatment, and you should continue to take ruxolitinib for as long as your doctor tells you to continue treatment.

• Do not stop taking ruxolitinib or change the dose of your treatment without first consulting your doctor.

• Signs and symptoms of myeloproliferative neoplasms are expected to return after interruption or discontinuation of treatment.

Prepared by James Nam, PharmD.

38 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

© ERPRODUCTIONS LTD / GETTY IMAGES

RADIATION & YOUR PATIENT

Incorporating Cardiac Care in the Oncology Setting Bryant Furlow Cardio-oncology is a rapidly emerging interdisciplinary field of medicine that addresses the concurrent treatment of cancer and cardiovascular disease, and the cardiovascular risks of cancer care. Radiation oncology nurses should be familiar with the conceptual underpinnings of this expanding discipline, the treatment of cardiovascular disease during cancer care, and the ways in which radiotherapy can impact patients’ cardiovascular health.

C

ancer treatments, including thoracic radiotherapy, can cause acute and late adverse cardiovascular events; up to one-third of women undergoing adjuvant breast cancer therapy will experience treatment-related cardiotoxicity.1 Cardiovascular tissues, including the

myocardium, pericardium, heart valves, and coronary arteries, are radiosensitive and are damaged to varying degrees when exposed to ionizing radiation.2 Patients undergoing high-dose radiation fractions (total radiation doses of 35 to 40 Gy or higher) and who are also receiving chemotherapy (anthracycline or monoclonal antibody therapies such as trastuzumab) are at particular risk of developing cardiotoxicities.2 Among patients with Hodgkin lymphoma or breast cancer, radiation therapy is associated with late cardiovascular disease, including coronary artery disease, valvular dysfunction, pericarditis, and cardiomyopathy.3 As baby boomers reach the highestrisk ages for cancer and cardiovascular disease, cancer care teams are increasingly caring for cancer patients with existing cardiovascular conditions that must be considered, accommodated, and monitored throughout cancer care — and must also educate patients about the cardiovascular risks of cancer treatments, and include cardiovascular health in cancer survivorship plans.3,4 There is, therefore, an urgent need to carefully coordinate clinical cancer care with cardiology — an emerging field at the crossroads of oncology, cardiology, and nursing known as cardio-oncology.2,5,6 COMBINING 2 DISCIPLINES Oncology nurses will be on the front lines of this discipline, coordinating and implementing the concurrent management of cancer and cardiovascular disease, monitoring and managing treatmentemergent cardiovascular complications, and helping cancer survivors understand and plan against their long-term cancer treatment-related cardiovascular risks.

Oncology nurses should therefore be familiar with the signs and symptoms of heart failure, cardiologic diagnostic tests, and surveillance practices.

As multimodality cancer treatment options become more complex and personalized, cardio-oncology clinicians will have to educate patients about the challenges of concurrent heart and cancer care, and will have to devise carefully planned interdisciplinary care plans that seek to avoid, monitor, detect, and manage a growing array of potential oncologic and cardiovascular interactions and complications.7-10 Professional oncology and cardiology organizations recognize the pressing need for coordinated cardio-oncology care and have begun to promulgate clinical practice guidelines.11-13 The American Society of Clinical Oncology (ASCO) has recommended, for example, that providers initiate cardiac dysfunction risks with at-risk patients prior to therapy to make sure that cancer care planning addresses patient priorities and values, and that high-risk cancer survivor populations (such as those undergoing thoracic radiotherapy in which the heart and major blood vessels fall within irradiated volumes, or cardiotoxic anthracycline cancer chemo-

There is an urgent need to coordinate clinical cancer care with cardiology. therapy) be educated about treatment options and cardiotoxicity prevention and screening strategies.6,11 Alkylating agents and antiestrogen therapy are also associated with heart complications.5 “Clinical suspicion for cardiac disease should be high and threshold for cardiac evaluation should be low in any survivor who has received potentially cardiotoxic therapy,” the ASCO clinical

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 39

RADIATION & YOUR PATIENT practice guideline states.11 “For certain higher risk survivors of cancer, routine surveillance with cardiac imaging may be warranted after completion of cancer-directed therapy, so that appropriate interventions can be initiated to halt or even reverse the progression of cardiac dysfunction.”

In 2016, the Society for Cardiovascular Angiography and Interventions (SCAI) published consensus recommendations for cardiology, oncology, and internal medicine clinicians about caring for patients with cardiovascular disease and cancer, noting that the evidence base is immature because cancer patients’ data is not included in percutaneous coronary interventions registries and cancer patients are typically excluded from randomized clinical cardiology trials.13 The recommendations detailed cardiovascular screening, cardioprotection, and invasive cardiovascular evaluations and therapeutic coronary interventions for patients with anemia and thrombocytopenia.13 The authors also recommended deferred cardiovascular stenting for heart disease during cancer treatment, when possible.13 INCORPORATING CARDIAC CARE

Despite efforts by professional bodies, however, implementation of cardiooncology programs varies widely between centers.6,12 A 2015 national survey found that formal training in cardio-oncology services are inadequate, with 70% of respondents reporting that the cardiovascular implications of cancer treatment are an important consideration, but only approximately

Prevention efforts should be included in these patients’ survivorship plans.

one-third of centers surveyed offered cardio-oncology services as part of preoperative patient consultations.12 Only 27% had established specialized cardiooncology services. Twelve percent had no cardio-oncology services but were in the process of establishing them.12 Although cardio-oncology programs vary, they should all involve risk stratification or screening of cancer patients for cardiovascular disease prior to cancerdirected therapy, coordinated care for patients undergoing concurrent cardiovascular disease-directed and cancerdirected care, prevention, rehabilitation and supportive care, and survivorship planning for patients whose cancer treatment likely increases their risk of late cardiovascular side effects.3,6 For example, baseline screening for dyslipidemia and diabetes mellitus, and baseline and surveillance electrocardiography (ECG) should be considered, and other imaging, including cardiac MRI or radionuclide ventriculography for left ventricular function, and possibly serum biomarker surveillance with high-sensitivity troponin, should be considered.3,6 Cardio-oncology programs involve timely consultations and diagnostic testing to avoid interruptions in cancer care. Urgent cardio-oncology procedures that should be undertaken in less than 2 weeks include new referral assessments for patients with pending or active cancer therapy and patients with symptoms of progressive heart failure, new or worsening chest pain (angina), or uncontrolled hypertension or arrhythmia.5,6 When cardiac dysfunction is detected, cardioprotection should be considered, including ACE inhibitors or beta blockers.2

survivors of childhood cancer who have undergone cardiotoxic cancer therapies.2 Breast cancer survivors frequently experience radiotherapy or other cancer treatment-related heart failure, cardiomyopathy, coronary ischemia, thromboembolism, heart arrhythmia, or valve or pericardial heart disease.1,5,14 Preexisting hypertension or left-ventricular dysfunction increases the risk of such late cardiotoxicities.1 Prevention efforts such as exercise and dietary considerations, and scheduled cardiovascular disease surveillance, should be included in these patients’ cancer survivorship care plans.1,3 Cardio-oncology is a new and rapidly expanding field faced with a limited evidence base. Oncology nurses will face increasingly complex management challenges in the concurrent management of cancer and cardiovascular disease, and preventing cancer therapyassociated cardiotoxicities. ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico.

REFERENCES 1. Schmitz KH, Prosnitz RG, Schwartz AL, Carver JR. Prospective surveillance and management of cardiac toxicity and health in breast cancer survivors. Cancer. 2012;118 (8 suppl):2270-2276.

2. Rose-Felker K, Border WL, Hong BJ, Chow EJ. Cardio-oncology related to heart failure: pediatric considerations for cardiac dysfunction. Heart Fail Clin. 2017;13(2):311-325.

3. Reddy P, Shenoy C, Blaes AH. Cardiooncology in the older adult. J Geriatr Oncol.

2017;8(4):308-314.

4. Lenihan D. Cardio-oncology: what is the best practice we can all strive for? Int J Cardiol.

2017;241:393-394.

5. Pituskin E, Paterson I, Cox-Kennett N, Rothe

CONCLUSION Because of latency periods for late cardiovascular effects following cancer treatment, long-term cardiovascular surveillance should be planned for

D, Perri M, Becher H. The role of cardiooncology in the interprofessional care of adult patients receiving cancer therapy.

Semin Oncol Nurs. 2017;33(4):384-392.

References continue on page 45

40 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

When There Are No Words

© GEORGEPETERS / GETTY IMAGES

Ann J. Brady, MSN, RN-BC

Sometimes what someone says with body language is clear.

However, sometimes it is not.

I

had the privilege of going to the National September 11 Memorial & Museum in New York City a couple of years ago.

As you enter what feels like a sacred space, there is a sequence of photographs of people reacting to the smoking Twin Towers. In nearly every photo, the person staring up at the tower has a hand clasped over his or her mouth in shock. It was not until I saw that photo display that I appreciated that that particular expression of shock and dismay transcends all human differences. There was something else, too: I did not need a verbal explanation to understand what those people were feeling.

Forward to December 2017; I live in Los Angeles, and we are in the middle of a firestorm of wildfires. When I opened the paper that morning the front page had several pictures showing the destruction, yet the photo that caught my attention was of a woman standing and looking at the flames.

Her hand was clasped over her mouth.

Sometimes what someone says with body language is clear. However, sometimes it is not, and we need to do a little exploring.

Rebecca Saxe, PhD, is a cognitive neuroscientist in the Department of Brain and Cognitive Sciences at MIT. She explains in a TED talk that beginning at approximately age 5 years we begin to learn to think about what another person is thinking.1 To do so, we follow cues and then put them into the context of the situation. Dr Saxe’s work focuses on a specific small area of our brain, the right temporoparietal junction, specifically tasked with figuring out what other people are thinking. The ability to process this information is based not on body language but on an understanding of circumstances. In an oversimplified explanation, her work gives credence to the saying, “I know what you are thinking,” in part because we know what we’d be thinking in that instance.

CASE Recently I was part of a family meeting in a patient’s hospital room. Maria had repeated hospitalizations for complications from her cancer and cancer treatment. These complications were on the precipice of outweighing the possible benefits. One look at her and it seemed obvious that, at least for the moment, she was not a candidate for more chemo.

Maria’s physician sat close to the head of the bed to discuss the situation with her. He was clearly engaged, nodding his head at all the right times and genuinely focused on her. Sam, her husband, sat on the window seat. He was not in the doctor’s visual field, though he was in mine.

Continues on page 42

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 41

COMMUNICATION CHALLENGES

When we are not certain, we need to clarify by asking “What are you thinking?” or “I noticed you frowned, what’s going on?”

“If we can get your labs to improve we may be able to restart the chemo.” The doctor said.

Maria nodded and he nodded back. Body language from the doctor relayed confidence and compassion. Body language from Maria indicated trust. However, I noticed that Sam frowned during the explanation; his eyes squinted as if there was too much light. I watched as he crossed his arms and fidgeted on the seat. What I sensed from his body language was that he was uncomfortable.

What I thought he was thinking was that the idea of more chemo did not make sense.

When the doctor stood, finished with his interaction, Sam stood up politely and extended his hand. “Thank you, doctor.”

But I did not want to ignore what I had seen pass on his face. It was incongruent with the nodding head of his wife and the doctor.

“Sam, do you have a question?” I asked.

He shook his head. I know many patients and families are reluctant to question the physician, worried it will undermine the doctor-patient relationship.

I hesitated for a moment. If Sam was willing to appear to agree, should I question that?

But I could not un-see his reaction. I nudged him forward because asking for clarity is important. If someone says something I don’t understand, I will ask what he or she meant; however, I do not always ask for clarity of nonverbal communication.

“It’s just that I noticed your face when [the doctor] mentioned the restart of chemo,” I said, “and I wasn’t sure if there was something you didn’t understand.”

“Well, there is one thing.” Sam rubbed his hand across his face, “I wondered what would happen if we decided not to do more chemo?”

Clarity.

DISCUSSION What role do body language and the information about right temporoparietal junction have in the setting of oncology? Studies show that body language is as accurate a reflection of our thoughts as the words we use. Think of the patient or family member who insists, “I’m doing great. I can handle it.” They tell us they

are fine when it is obvious they are not. But, it isn’t just their body language that we interpret.

We contextualize what they are saying and filter it through that part of our brain tasked with thinking about what others think. We may choose to take the words at face value, worried that it is presumptive or intrusive to question what they say. Yet clarity is essential.

There are other times when instead of noticing body language, I focus on what I need to teach or explain and may ignore nonverbal cues to concentrate on tasks. Those are the times I miss the shouts of nonverbal messaging and the insight of considering what the person is thinking. Since health care decisions are such a personal choice, there are times I put aside exploring what I believe a patient or family member is thinking.

The meeting with Maria and Sam was not unusual. The atmosphere was open and the doctor readily engaged with Maria. If I were sitting in a different chair, I would have missed seeing Sam’s reaction. Alternatively, I might have decided to wait until later to ask Sam what questions he had.

The dynamic of care in the hospital is not always conducive to extended conversations, yet the best time to address questions and prevent misinformation is in the moment.

Communication challenges abound in oncology care. As nurses, we are the health care provider most inclined to help make sense of what otherwise does not make sense at all. When we are not certain, we need to clarify by asking “What are you thinking?” or “I noticed you frowned, what’s going on?”

We must be the one to communicate when there are no words. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

REFERENCE 1. Saxe R. How we read each other’s minds [video].

Oral presentation at: TEDGlobal 2009; July 2009; Oxford, UK. http //www.ted.com/talks/rebecca_ saxe_how_brains_make_moral_judgment.

Accessed January 12, 2018.

42 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

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• Cancer treatment regimens

• Easy-to-use medical calculators

• Downloadable patient fact sheets

• Comprehensive drug slideshows

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The Role of the Oncology Nurse in an Effective Palliative Care Family Meeting Bette Weinstein Kaplan

O

ncology nurses are in the perfect position to implement ideal care for their patients via the use of the family meeting in palliative and end-of-life care. This type of meeting provides an opportunity to coordinate the responsibilities of caregivers and clinicians with patient needs, according to a study

by Myra Glajchen, DSW, director of medical education, MJHS Institute for Innovation in Palliative Care, New York, and Anna Goehring, MD, palliative care physician, MJHS Hospice and Palliative Care, New York.1 Oncology nurses usually spend more time with patients than other staff and are able to answer patients’ questions about their medical conditions and discuss end-of-life issues with patients when they are ready to do so. They are also in a good position to evaluate caregivers’ condition and determine how involved caregivers want to be in helping patients make crucial decisions.

These decisions are often difficult, yet Ms Glajchen and Dr Goehring write that end-of-life communication skills are not emphasized in the nursing literature.1 They note that the role of the oncology nurse in family meetings is not clear and that there has been little guidance on evaluating and managing caregiver distress.

Family caregivers have their own obligations but often bear heavy,

difficult caregiving responsibilities in addition to handling their own personal concerns. Nurses can evaluate the extent to which their caregiving burdens go beyond their skills to cope and provide what their ill family member needs. Oncology nurses also are responsible for assessing the strength of the relationship between patients and their caregivers. A satisfying relationship correlates with a better commitment on

The researchers caution there should be more caregivers than staff present. the part of the caregiver, although this must be balanced with other activities to avoid caregiving becoming fraught and burdensome.

There must also be a balance with other family members; the researchers stress that a diagnosis of cancer for one family member affects the entire family.

Caregivers for patients who are being actively treated for disease are in better physical and emotional health than caregivers for patients receiving palliative and end-of-life care. Oncology nurses should use family meetings to evaluate and structure caregiving situations for patients, caregivers, and their families.

THE MEETING There are a number of reasons for healthcare teams to request a family meeting. Often such meetings are about a decline in a patient’s medical condition or another change in the patient’s prognosis that requires making decisions about new treatments and different options for advance care planning. Meetings may also be called for specific purposes such as completing living wills; do not resuscitate (DNR) and do not intubate (DNI) orders; or to discuss mechanical ventilation, artificial hydration, and nutrition.

The nurse’s role is key in these decisions.

Oncology nurses are qualified to understand medical information, which they can easily interpret for patients and their families at these meetings. For this reason, oncology nurses should obtain and review all updated information from the patients’ clinicians prior to the meeting.

With the oncology nurse at the meeting, other clinicians only need to attend if doing so serves a specific purpose. However, the participation of involved staff from other disciplines concerned with the patient’s care is helpful. Caregivers the healthcare team or patient wants to invite should attend the meeting, although the researchers caution there should be more caregivers than staff present so as not to overwhelm the family at this difficult time. The care team leader should explain why the meeting was called, provide a clear

44 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

agenda, and should request all attendees to mute their cell phones and pagers during the meeting. A member of the healthcare team should take notes; the investigators suggested using the Family Meeting Report (Figure 1) and documenting the meeting in the electronic medical record.1 A family meeting takes time: at least 1 hour for preparation, 1 hour for the actual meeting, and 30 minutes to 1 hour for follow-up is required. Despite the work-intensive nature of a palliative care family meeting, the oncology nurse can be a true asset, lowering stress and offering information, realistic hope, supportive care, and comfort to patients, caregivers, and other family members. ■

FAMILY MEETING REPORT DATE:

LOCATION:

PARTICIPANTS:

HCP:

YES 

SURROGATE:

NO 

NAME:

YES 

NO 

PHONE:

ADVANCE DIRECTIVES:

 DNR

INDICATION FOR FAMILY MEETING:

 LIVING WILL

PRESENT:

YES 

NO 

 POLST

 UPDATE IN MEDICAL CONDITION  GOALS OF CARE  DISCHARGE PLANNING  OTHER

PATIENT/FAMILY QUESTIONS/CONCERNS: CLINICIAN REVIEW OF MEDICAL STATUS, TREATMENT OPTIONS, POTENTIAL OUTCOMES: AREAS OF CONSENSUS: AREAS FOR FURTHER CLARIFICATION:

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

FOLLOW-UP:

YES 

NO 

COMPLETED BY:

REFERENCE

BY WHOM: DATE:

TIME:

CONTACT INFORMATION:

1. Glajchen M, Goehring A. The family meeting in palliative care: role of the oncology nurse.

FIGURE 1. Template for a standard Family Meeting Report.

Semin Oncol Nurs. 2017;33(5):489-497.

Radiation & Your Patient

cardio-oncology. Trends Cardiovasc Med.

of Cardiology; June 22, 2015. http://www.

Continued from page 40

2014;24(7):285-295.

acc.org/about-acc/press-releases/2015/06/

10. Maas AH, Ottevanger N, Atsma F, Cramer MJ, 6. Parent S, Pituskin E, Paterson DI. The cardio-

Leiner T, Poortmans P. Cardiovascular surveil-

oncology program: a multidisciplinary

lance in breast cancer treatment: a more

approach to the care of cancer patients

individualized approach is needed. Maturitas.

with cardiovascular disease. Can J Cardiol.

2016;89:58-62.

2016;32(7):847-851.

22/14/18/cardio-oncology-services-mayimprove-patient-care-if-more-widelyavailable. Accessed December 12, 2017.

13. Iliescu CA, Grines CL, Herrmann J, et al. SCAI expert consensus statement: evaluation,

11. Armenian SH, Lacchetti C, Barac A, et al.

management, and special considerations

Prevention and monitoring of cardiac

of cardio-oncology patients in the cardiac

oncology, immuno-oncology, onco-cardi-

dysfunction in survivors of adult cancers:

catheterization laboratory (endorsed by

ology and onco-immunology. Int J Cardiol.

American Society of Clinical Oncology

the Cardiological Society of India, and

2016;223:254-257.

clinical practice guideline. J Clin Oncol.

Sociedad Latino Americana de Cardiologia

2017;35(8):893-911.

Intervencionista). Catheter Cardiovasc Interv.

7. Kounis NG, Koniari I, Hahalis G. Cardio-

8. Sheng CC, Amiri-Kordestani L, Palmby T, et al. 21st century cardio-oncology: iden-

12. Cardio-oncology services may improve

tifying cardiac safety signals in the era of

patient care if more widely available:

personalized medicine. JACC Basic Transl Sci.

American College of Cardiology aims to fill

Cardiotoxic heart failure in breast cancer

2016;1(5):386-398.

gaps in cardiovascular care for cancer

survivors: a concept analysis. J Adv Nursing.

patients. Washington, DC: American College

2016;72(7):1518-1528.

9. Herrmann J, Lerman A. An update on

2016;87(5):E202-E223.

14. Harrison JM, Pressler SJ, Friese CR.

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 45

FROM Supporting Young Adult Patients With Metastatic Cancer Sarah Paul, LCSW

“BUT YOU DON’T LOOK SICK”

One of the greatest challenges this patient population faces is the shifting parallel between being on active treatment but not fitting the visual stereotype of a cancer patient. Young adults navigating metastatic disease must come to terms with the idea that they may be on treatment indefinitely. In addition, due to the novel advancements in oncology care, many treatments do not cause the same physical side effects as standardized treatments of the past.

Young adults commonly feel frustrated by people who lack compassion and understanding for their journey.

Often, they must manage the expectations of loved ones who assume they are cured or no longer experiencing side effects or difficulties. Those with stable metastatic disease continue to work; thus, they must also manage

disclosure in the workplace and how it may affect their career goals. Often, places of work have a difficult time understanding why a young adult might need time off for additional treatment when they “look great.”

ACCEPTING THE REALITY OF A METASTATIC DIAGNOSIS

Another challenge that plagues this specific population is the need to accept the reality of a metastatic diagnosis.

Many lack an understanding of what the term metastatic implies. Although it does not have the same negative connotation as a few years ago (we are seeing more and more people live longer with stage IV illness), it does mean that remission is not an option.

Young adults must factor this idea into their life goals and plans for the future.

Accepting this reality is challenging and often requires additional support from an oncology professional, a licensed therapist, peer support, or group therapy. “The most challenging part so far has just been assimilating the fact that the metastatic diagnosis meant my life was not going to continue how I envisioned. I think it took me a long time simply to adjust to that and then start to find ways to still pursue my interests and find meaning in my everyday life,” explains a young adult patient.

THE ROLE OF GRIEF AND CREATING A LEGACY

Young adults with metastatic illness may experience grief milestones associated with normal adult life events.

They may have to adjust their life goals to find continued meaning, even if this

The young adult population — ages 20 to 39 years — continues to face unique challenges in the wake of a cancer diagnosis.

46 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

© HERO IMAGES / GETTY IMAGES

C

ancer is diagnosed in more than 70,000 young adults (YAs) each year in the United States.1 The YA population (ages 20 to 39 years) continues to face unique challenges in the wake of a cancer diagnosis. These challenges result in a myriad of psychosocial needs that may be different from those of other populations within the oncology community. Young adults are widely believed to be less likely to develop cancer due to their age, which can lead to misdiagnoses and delays in starting treatment, with many having advanced stage or metastatic cancer at diagnosis.

Although the survival rate for young adults is not as high as in other age populations, many survivors are becoming outliers in research by outliving survival statistics. Higher survival rates have shed light on the complex psychosocial needs of this population.2 Oncology professionals’ awareness of these needs is imperative to provide specialized support for this population. This article is informed by research and personal experiences of young adults with metastatic disease.

With CancerCare®, the difference comes from: • Professional oncology social workers • Counseling and support groups

• Financial assistance • Resources and education

Access our services by telephone, face-to-face and online.

All CancerCare services are free of charge.

FROM means grieving the loss of a dream job, planning for a family, or the ability to travel freely. Young adults are prone to comparing themselves with their peers, and finding dissatisfaction in their daily life. Those with metastatic illness may feel pressure to accomplish certain life tasks such as finding a partner or starting a family. They may feel conflicted as others urge them to follow their dreams because their life may be cut short.

Similarly, many find themselves faced with their sudden mortality and the idea that they must create something to leave behind. This idea of constructing a legacy can cause emotional distress, as this idea is new to many young adults.

It is important that this population find emotional support to process what a personal legacy may signify and how they can find meaning in their situation.

CREATING A SUPPORTIVE NETWORK

Once the challenges are identified, how do you help? Young-adult-specific support is often hard to come by; however, specialized support through individual telephone counseling, in-person counseling, and online and in-person support groups is available through CancerCare. Young adults report that having a supportive space to process these challenges has allowed them to further explore their experience and come to terms with their personal reality.3 Peer support is acknowledged as an important part of the process; speaking to other young adults with metastatic disease can decrease isolation and emotional distress. Encourage young adults to reach out for support and to extend their network beyond primary means. ■

Sarah Paul is the Child and AYA Program coordinator at CancerCare.

REFERENCES 1. Cancer Facts & Figures 2017. Atlanta, GA: American Cancer Society; 2017.

2. Bolte S. Young adults (20 to 39) with cancer. In: Christ G, Messner C, Behar L, eds. Handbook of Oncology Social Work: Psychosocial Care for People with Cancer.

New York, NY: Oxford University Press; 2015:507-513.

3. Closing the gap: Research and Care Imperatives for Adolescents and Young Adults With Cancer. Report of the Adolescent and Young Adult Oncology Progress Review Group.

Bethesda, MD: National Cancer Institute; 2006. NIH Publication No. 06-6067. https://www.cancer.gov/types/aya/ research/ayao-august-2006.pdf. Accessed December 13, 2017.

Time-saving clinical tools for patient-centered care.

OncologyNurseAdvisor.com provides all of the tools you need to better care for your patients.

• Cancer treatment regimens • Downloadable patient fact sheets

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

Visit www.OncologyNurseAdvisor.com today.

48 ONCOLOGY NURSE ADVISOR • JANUARY/FEBRUARY 2018 • www.OncologyNurseAdvisor.com

© QA INTERNATIONAL / SCIENCE SOURCE

ASK A PHARMACIST

Effective Management of Vaginal Dryness; Safe Drug Disposal What are some nonhormonal treatments that can improve vaginal dryness in women with a history of breast cancer?

— Name withheld on request

Nonhormonal treatments for vaginal dryness predominantly consist of vaginal lubricants and lifestyle modifications. Women with vaginal dryness should avoid the use of scented products, such as pantiliners and soaps, as these may increase irritation to the genital area.

Another important issue is smoking. Use of tobacco products is associated with anticholinergic effects, and can worsen vaginal dryness. Women

complaining of vaginal dryness who are current tobacco users should be counseled regarding smoking cessation both to help improve their symptoms as well as obtain the myriad of other health benefits associated with smoking cessation.

Extending foreplay as well as regular sexual activity may also benefit women with vaginal dryness that causes discomfort during sexual activity.

Other nonhormonal interventions include vaginal lubricants. Short-acting lubricants used before sexual activity (eg, Astroglide, KY Jelly) may reduce discomfort during intercourse, and long-acting lubricants used on a regular basis (eg, Replens) may reduce vaginal itching and irritation.

Ospemifene (Osphena) is a selective estrogen receptor modulator, available via prescription as an oral pill, used to treat postmenopausal vaginal atrophy and discomfort. Ospemifene is not recommended for use in women with a history of breast cancer as it has not been adequately studied in this population.1 Women with vaginal symptoms should also be encouraged to discuss their symptoms with their gynecologist and undergo a thorough physical examination and evaluation for any other contributing factors. ■ REFERENCE 1. Osphena [package insert]. Florham Park, NJ:

SAFE DRUG DISPOSAL The next Drug Enforcement Administration (DEA)-hosted Drug Take Back Day is scheduled for Saturday, April 28, 2018. Patients and their caregivers can dispose of expired or unwanted medications at these events, including controlled substances such as opioid pain medications. To find a location near you, visit www.dea diversion.usdoj.gov/drug_disposal/ takeback/.

Many communities also have drop boxes for disposal of medications available year round. These drop boxes can be found by searching the collection site locator at https:// takebackday.dea.gov/. If patients have hazardous medications (such as some oral chemotherapy drugs) or medications in syringes (such as some blood thinners), they should check with the location to be sure these are accepted.

Some companies also produce envelopes that can be purchased and used to return unused medications. If these are not available and patients are not able to access a Drug Take Back Day event, medications can be disposed of using the Environmental Protection Agency (EPA) guidelines, available at www.epa.gov/sites/production/files/2015-06/documents/ how-to-dispose-medicines.pdf/.

Shionogi Inc; 2015.

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

www.OncologyNurseAdvisor.com • JANUARY/FEBRUARY 2018 • ONCOLOGY NURSE ADVISOR 49