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ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017

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July/August 2017

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FEATURE

■ Earn 0.75 contact Understanding Yourhours Patient:

Key to Successful Outcomes FREE CONTINUING

EDUCATION INSIDE!

Text here, PAGE xx FEATURE

TreatmentRelated Late Effects Identified in HEADER HERE Some Survivors Text here

HEADER JOURNAL REVIEW Rolapitant Effective in Relieving HERE Delayed CINV Text here

HEADER HERE COMMUNICATION Text here CHALLENGES

The Great Cancer Masquerade: HEADER HERE Grief as Anxiety, Control, Anger Text here

ISSUES CANCER HEADERINHERE SURVIVORSHIP Text here

Text Message System Relies on Common AYA Behavior to Enhance Survivorship Care

FROM CANCERCARE VOLUME 8, NUMBER 4

Gay Men and Overcoming the Stigma of a Cancer Diagnosis

Workshop Focuses on Bringing Survivors Back to the People They Are Collaborative program helps patients rebuild their physical self after cancer treatment.

PUBLISHING STAFF Editor Joyce Pagán editor.ona@haymarketmedia.com

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EDITORIAL BOARD

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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), July/August 2017, Volume 8, Number 4. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. Oncology Nurse Advisor is available for single copy purchases at the following rates. Price per copy: USA $20; Foreign $30. To order call (800) 558-1703. For advertising sales, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

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

6 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017 • www.OncologyNurseAdvisor.com

CONTENTS

July/August 2017

IN THE NEWS • Pediatric Self-Report on AEs Reliable, Accurate • Study Questions Standard Dosage for Pembrolizumab in Metastatic NSCLC • Aspirin, NSAID Use Correlates With Improved Overall Survival in CRC … and more

IN THE NEWS : ASCO 2017 • Survival Breakthrough for Prostate Cancer • CALM Intervention Eases Distress in Patients With Advanced Cancer • Older Adults Under-represented in Cancer Drug Clinical Trials … and more

IN THE NEWS : NAVIGATION SUMMIT 2017 • Ensuring Patient Adherence to Oral Therapies • A Better Breast Cancer Diagnosis Process • Developing a CT Lung Cancer Screening Program … and more

45 32

FEATURES Workshop Tackles a Significant Treatment-Related Issue Bette Weinstein Kaplan

Understanding Your Patient: Key to Successful Outcomes Carol Blecher, MS, RN, AOCN, APNC, CBCN

47 FIND US ON

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

• Easy-to-use medical calculators

• Downloadable patient fact sheets

• Comprehensive drug slideshows

Visit www.OncologyNurseAdvisor.com today.

FEATURE ARTICLE Novel 3D Marker Reduces Radiation, Improves Cosmesis in Breast Conserving Surgery

CONTENTS

July/August 2017

Two recent studies examined the benefits of using a 3D bioabsorbable marker to indicate the tumor bed in women with breast cancer who underwent BCS. STAT CONSULT

FEATURES (continued) 40 Treatment-Related Late Effects Identified in Some Survivors Bette Weinstein Kaplan

JOURNAL REVIEW Rolapitant Effective in Relieving Delayed CINV

Ipilimumab (Yervoy)

FDA approval of ipilimumab, a recombinant, human CTLA-4–blocking monoclonal antibody indicated for the treatment of unresectable or metastatic melanoma, was expanded to include pediatric patients 12 years and older.

John Schieszer, MA

ASK A PHARMACIST 43

RADIATION & YOUR PATIENT Radiotherapy Outcomes Improved With Lower Doses, More Fractions Bryant Furlow

Blood Tests Before Daratumumab

Why is type and crossmatch needed before starting patients on treatment with daratumumab (Darzalex)? Vaccines to Avoid With Chemotherapy

COMMUNICATION CHALLENGES The Great Cancer Masquerade: Grief as Anxiety, Control, Anger Ann J. Brady, MSN, RN-BC

ISSUES IN CANCER SURVIVORSHIP Text Message System Relies on Common AYA Behavior to Enhance Survivorship Care Bette Weinstein Kaplan

Which vaccines should be avoided in patients receiving chemotherapy? PUBLISHERS’ ALLIANCE: DOVE PRESS Chemotherapy-associated Paronychia Treated With 2% Povidone-Iodine: A Series of Cases

This research examines cases of chemotherapy-induced nail changes in individuals treated with taxanes and EGFR inhibitors. Cancer Management and Research

FROM CANCERCARE Gay Men and the Stigma of a Cancer Diagnosis William Goeren, MS, LCSW-R, OSW-C, ACSW

ON THE

WEB

www.OncologyNurseAdvisor.com • JULY/AUGUST 2017 • ONCOLOGY NURSE ADVISOR 13

IN THE NEWS Pediatric Self-Report on AEs Reliable, Accurate Children experience multiple subjective adverse events (AEs) such as fatigue, pain, and sadness; however, children are not routinely asked about these events, resulting in adverse events being underreported and undermanaged in this patient population. The total impact of treatment is thus not fully treated or documented, explained Pamela Hinds, PhD, RN, FAAN, of the Children’s National Medical Center, Washington DC. Assessment of treatment-related adverse events in pediatric patients is limited to objective indicators graded by clinicians. Therefore, Dr Hinds and colleagues sought to create and validate a selfreport measure of subjective adverse events for use with patients aged 7 to 20 years undergoing cancer treatment. For the study, 4 pediatric oncology clinicians reviewed all 790 common terminology criteria for adverse events (CTCAE) items and achieved consensus on 262 items. Using a Delphi approach, a panel of experts identified which of the items could be accurately reported by patients aged 7 to 20 years. Semistructured interviews were conducted with 96 children and their guardians regarding the patients’ adverse event experiences. In addition, cognitive interviews were conducted with 81 children and their guardians regarding child-friendly terminology for adverse events, directions, and time period for a self-report AE measure in pediatric patients. Cognitive interviews were conducted twice because agreement on 12 of the terms was not achieved in the first interviews, and 62 terms were translated from medical jargon to child-friendly and adolescentfriendly terms. Lastly, the measure was constructed and field tested. Results revealed that most children were able to understand the 7-day recall period used for AE interviews. Although younger children preferred that the AEs be read to them, patients aged 7 years and older and their guardians were generally able to understand and willing to report on cancer treatment AEs they experienced using the 7-day recall period.

Lenvatinib Improves Overall, ProgressionFree Survival in RR-DTC in Older Patients A sub-analysis of the phase 3 SELECT trial (ClinicalTrials. gov identifier: NCT01321554) on the impact of age on the safety and efficacy of lenvatinib in patients with radioiodinerefractory differentiated thyroid cancer (RR-DTC) showed that lenvatinib increased progression-free survival (PFS). For the analysis, SELECT participants were randomized to 24 mg/day lenvatinib (n=261) or placebo (n=131). Both groups were stratified by age: 65 years and younger (median age, 56 years) and older than 65 years (median age, 71 years).

PFS was significantly improved with lenvatinib vs placebo in both age groups: 20.2 months vs 3.2 months, respectively, in the younger age group and 16.7 months vs 3.7 months, respectively, in the older age group. Among patients receiving lenvatinib, overall survival (OS) was improved in the older patients. However, overall response rates (72% vs 55%), time to first dose reduction (3.7 months vs 1.5 months), and percentage of grade 3 or higher treatmentrelated adverse events (67% vs 89%) were significantly improved in the younger patients compared with the older patients. Read more at http://bit.ly/2uWJfKJ.

14 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017 • www.OncologyNurseAdvisor.com

Read more at http://bit.ly/2vy2HNp.

The key to improving lung cancer prognosis is, as with most cancers, early detection. The National Lung Screening Trial, completed in 2010, concluded that early detection of lung cancer via low-dose CT (LDCT) lung screening reduced mortality rates Patient follow-up an by 20% in high-risk patients. This ongoing challenge prompted the US Preventive Services Task Force (USPSTF) to recommend annual screening, followed by CMS approval for Medicare coverage of screening high-risk persons (based on age and smoking history). The CT Lung Program at CHI Memorial in Chattanooga, Tennessee, was initiated in 2014, and a steering committee of physician champions, other stakeholding physicians, administration personnel, and the thoracic oncology nurse navigator assembled to establish a viable Thoracic Oncology Lung Center of Excellence that included a CT lung screening program. Steps taken to build our program included: implement a scheduling and billing process that reflected Medicare guidelines; develop an order form that incorporated required information and listed the high-risk guidelines; initiate educational newsletters and telephone outreach for physicians and their office staff; plan community outreach and marketing via TV, radio, and newspaper advertisements; and establish smoking cessation classes at various locations throughout Chattanooga. An early challenge was how to gather the data (28 points in all) required by the Lung Cancer Screening Registry, an American College of Radiology (ACR) national registry, to satisfy Medicare billing requirements — we hired a data

Multifaceted Role Includes Palliative, Supportive Care Nurse navigators are well-suited to provide effective palliative and supportive care that improves quality of life for both the patient and the family. Palliative care, as it pertains to patients with cancer, is defined as patient/family-centered care that optimizes quality of life through anticipation, prevention, and treatment of suffering. By virtue of their education and skill set, nurse navigators are as suited to helm the palliative care team as palliative care nurse practitioners (PCNPs). Clinically, the skill set for nurse navigators and PCNPs match; however, some differences exist in education and requirements. Their role in the continuum of care differs only in that nurse navigators are tasked with orienting patients to the cancer system in addition to nursing tasks involving emotional/educational support, advocacy, patient referrals, and to collaborate with other health care providers. The CARES tool is a very effective tool for managing patient and family needs at the end of life. CARES is an acronym for an organized educational guide that addresses the most common symptom needs of the dying: Comfort, Airway, Restlessness and delirium, Emotional and spiritual support, Self-care. But the most compassionate action a nurse navigator can take is to actively listen and give honest and open responses that show genuine caring. Navigators may serve as a therapeutic presence that helps patients and families avoid a sense of abandonment. ■ Read more at http://bit.ly/2tCqV7M.

www.OncologyNurseAdvisor.com • JULY/AUGUST 2017 • ONCOLOGY NURSE ADVISOR 31

30 volunteer LCPNs, 14 elected to staff a weekly diseaseoriented clinic 3 to 4 hours per week. LCPNs made 1034 patient encounters (484 with new patients, 550 with repeat patients) through June 2016. LCPNs completed an encounter form after each patient visit. These encounters resulted in referrals to the following resources: patient and family resource center (74%), community resource information (30%), financial counseling (27%), and social work (25%). The LCPNs in the program reported feeling adequately trained to provide information and meet the needs of patients with cancer during patient encounters.

FEATURE | Side-Effect Management

Workshop Tackles a Significant Treatment-Related Issue Collaborative program teaches patients how to cope with and repair the changes to their physical appearance brought on by cancer treatment. BETTE WEINSTEIN KAPLAN

ook Good Feel Better (LGFB) is a program that has helped nearly 1 million women with cancer in the United States since it began in 1989. More than 2000 facilities host 15,000 LGFB workshops annually and another 150,000 patients and survivors are helped through LGFB’s online and virtual services and support. Louanne Roark, executive director of the Look Good Feel Better Foundation of the Personal Care Products Council, explained what the program has to offer participants undergoing cancer treatments — men and teens, as well as women — to Bette Weinstein Kaplan, a contributing writer for Oncology Nurse Advisor. Look Good Feel Better is designed to help women by giving them an effective and practical intervention during the course of cancer treatment at a time in which they begin to experience side effects of their treatment. Those side effects may be hair loss and/or changes in their skin (becomes dry, blotchy, and discolored). Some women may lose their eyebrows and eyelashes, which unexpectedly changes their entire look. Many women say the moment they begin to see the effects of their treatment is when they look in the mirror and do not recognize themselves. That is the point at which they acknowledge that they do look sick and they do have cancer. It is a moment of reckoning.

OFFERING A RESPITE What Look Good Feel Better offers these women is what the organization describes as a “respite” 32 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017 • www.OncologyNurseAdvisor.com

during this stressful and discouraging time. The program involves group workshops, usually available in hospital environments, facilitated by trained and licensed hair stylists and cosmetologists who teach the women how to use different products to improve their physical appearance. The professionals who volunteer to work in the program complete the Look Good Feel Better certification program. They are well-prepared to deliver the program, and to anticipate what women who are experiencing cancer might need when they come into a workshop. Group workshops The women who attend the workshops are able to be out and about despite their cancer. They might choose to participate in a workshop before or after a doctor visit or treatment, which is often held at the cancer center or treatment clinic. Typically 5 to 8 patients and 2 to 3 volunteers participate in each workshop. The participants and professionals spend 2 hours together. One advantage of the program is that women have a chance to be with other women going through similar experiences and facing similar challenges during the course of their treatment. The workshop may be the only time they come together during their treatment, and the camaraderie and community built into that workshop is a significant component of what the organization wants to bring to these women. In addition, workshop participants receive very practical guidance. Each woman is given a kit of skin care and cosmetic products donated by the beauty industry, and they literally empty the bag and proceed to learn what the products are and how to use them to address their specific needs during cancer treatment. Hair loss Approximately 45 minutes of the workshop is focused on hair loss. The women learn how to buy a wig, fit it, and take proper care of it. They also learn how to use alternatives to wigs, such as scarves, turbans, or combinations of those things to create a look they are comfortable with. The goal is for the woman to be able to look in the mirror and get back to recognizing herself, and to feel comfortable in her own skin again. What an observer sees at the end of a workshop is women smiling, laughing, and having fun together. They exchange phone numbers and develop relationships within a community of other survivors. Styling Each workshop includes a styling component presented in a video created with the expertise of stylist Stacy London of What Not To Wear fame. The video addresses issues such as weight gain or loss and how to choose and adjust clothing to cover and protect a chest or arm stent.

London introduces the concept of color choices during chemotherapy, offering suggestions on how to choose colors that minimize the visual impact if the skin is becoming discolored: brighter colors work best. The women are encouraged to be conscious of what colors work best with their skin, hair, and eye color, and to make adjustments as their skin tone changes. Also participating in the program are celebrity makeup artist Carmindy and renowned hair stylist Oribe. The styling tips learned at a LGFB workshop are, of course, just as helpful after treatment is completed as well.

That is the goal: for participants to feel good about themselves again and be able to take control and get back to being the people they are. TAKING BACK CONTROL Look Good Feel Better workshops offer a great deal of information while presenting an opportunity for women to enjoy the moment. Women are able to forget about their cancer for a couple of hours. Often participants are somewhat shy about taking off their wig or scarf or reticent to talk about what they are going through at the beginning of a program, but the entire dynamic changes 10 to 15 minutes into the workshop. As the women begin to relax, the volunteers draw them out and get them to engage with the others in the group. They begin to have fun and laugh, and the workshop becomes more of a gathering of friends. Program participants tell the volunteers that the information they learned in the workshop helps them through their course of treatment. One reaction women often express at the conclusion of the workshop is, “Wow! I can’t believe I look like this! I’ve got to call my husband. He’s taking me out to dinner tonight!” The women often get a wonderful reaction from their loved ones, who are pleased that they attended the program and are feeling a much greater level of confidence and self-esteem as a result. That is the goal: for participants to feel good about themselves again and to be able to take control and get back to being the people they are. WHO SHOULD GO AND WHEN The normalcy element is one of the key areas that contributes to a positive outcome. This disease is so disruptive; it takes

www.OncologyNurseAdvisor.com • JULY/AUGUST 2017 • ONCOLOGY NURSE ADVISOR 33

FEATURE | Side-Effect Management control out of a woman’s hands. The hair loss and appearance changes rob women of their choice of when and how to share information about their cancer with others. Look Good Feel Better returns that control to the women who participate in workshops so they get to decide when and how to tell someone they are ill. After a workshop, the woman knows what to do about how she looks. She can manage it, put it aside, and continue on, getting through and beyond treatment. Therefore, Look Good Feel Better recommends that women attend a workshop when they first begin to notice appearance changes. They should not wait until they are so far along that their appearance has become a challenge for them. They need to learn early on what they can do to manage their appearance when they are just beginning to see hair loss and skin changes. For teens A smaller-scale program designed for teenagers is available in 18 cancer centers around the country. The format mixes boys and girls together in a face-to-face workshop format with the boys at one table and the girls at another. These programs also provide online support. Teen girls want to learn how to use makeup; teen boys want to learn how to correct dry or discolored skin and perhaps how to treat acne. The teen program is most successful when matched up with other programs offered by hospitals that treat teen patients. This age group is more receptive when oncology nurses can offer Look Good Feel Better along with other teen-oriented programs. For men Although men undergoing cancer treatment prefer to avoid a group experience, they are still interested

in understanding what their options are. Online delivery seems to be effective for them. The Look Good Feel Better website has a section just for men with appropriately targeted instructional videos. The focus is on skin care and how to combat issues such as shaving and dry skin during cancer treatment. The videos offer tips on how to manage changes in their appearance. For example, a bronzing product can add some color to the face without actually being makeup, and concealers can subtly cover dark circles under the eyes. Eyebrows can be recreated using eyebrow product kits. Hair loss is not as significant an issue for men, and most would simply wear a hat. The men’s section also includes fitness tips and exercise routines specifically for men. TIPS FOR THE ONCOLOGY NURSE Oncology nurses are encouraged to make their patients aware of the LGFB program early on. One comment women will make when they are told that they have cancer and will need treatment is, “Oh my goodness. I could lose my hair! My appearance might change.” This program provides the oncology nurse with a tool for counseling patients. They are able to say to the patient, “Yes, you’re having treatment, and these are some of the adverse effects you may experience. But we also have a program that can assist you with that.” Look Good Feel Better is designed to benefit women of all ages who have all forms of cancer. No matter what type

Look Good Feel Better Transformations Participants receive lessons on skin care, cosmetics, wigs, and other options for improving their appearance that brighten their outlook of themselves. They also receive a gift bag full of sample products to continue their rebuilding process at home.

BEFORE

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AFTER

[Nurses] are able to say, “These are some of the adverse effects you may experience. But we have a program that can assist you with that.” of cancer a woman might have, if she is undergoing treatment and is concerned about changes in her appearance, the Look Good Feel Better volunteers are happy to help her and welcome her in a workshop. Look Good Feel Better offers a wide range of materials for oncology nurses, including general information brochures they can put in patient information packets. Posters to display in the hospital are especially valuable when hosting the workshops. Since more than 2000 facilities host workshops, the Look Good Feel Better program is available at many of the major cancer centers around the country. Some nurses introduce the program as part of an information packet early on in treatment, sometimes on the first day the patient receives chemotherapy or just before. Information about the program is often kept in the treatment areas. For example, some treatment centers keep brochures about Look Good Feel Better in the infusion room. At some hospitals, the care coordinator explains the program when they visit patients in their hospital rooms after surgery, encouraging them to consider participating when they feel up to it. AN ARSENAL OF TOOLS Website The Look Good Feel Better website is robust and

rich in information for patients to utilize based on their particular needs, including • Videos offering detailed step-by-step instructions • Virtual Live Streaming program, a recorded workshop for patients at home to follow along with the workshop. • Virtual Makeover Tool, which allows a woman who is not sure if she wants to attend a workshop, or if it will be of benefit to her, to get a sense of what she might learn. Some nurses use this feature to introduce the program to patients while they are in the infusion chair. • Program Finder, which helps potential participants find Look Good Feel Better workshops in their area. Makeover iPhone app The virtual makeover is somewhat abbreviated in the app version, but it offers a similar chance for the patient to experiment with her look. Health Care Provider Tool Kit Look Good Feel Better is currently working on a health care provider digital tool

kit for the oncology nurse, which will package all of the resources available for helping patients. The tool kit should be available before the end of the 2017. Volunteers Look Good Feel Better recruits volunteers at local and national levels, and currently, the organization is working with approximately 6000 volunteers across the country. The program works through a collaboration of the national Look Good Feel Better Foundation, an adjunct of the Personal Care Products Council, the American Cancer Society, which recruits volunteers at the grass roots level, and the Professional Beauty Association (PBA). Many of the beauty professionals in the program are recruited from local salons through the PBA. The volunteer professionals are always delighted to use their skills to help women at a very critical point in their lives. Outreach The goal is to help as many women as possible at all stages of cancer treatment at the point where they are having difficulty and need support. On an annual basis, across all of the 2000 facilities that offer workshops, Look Good Feel Better reaches approximately 50,000 women. They also offer one-on-one consultations in some locations where the group workshops are not easily accessible, such as rural areas. In this program, salon-based professionals consult with patients in their salons, providing the same information that the women would get by attending a group workshop. At-Home Self Help Materials consist of a DVD with an instructional video and a patient participant workbook with step-by-step instructions that is mailed to a participant’s home. The women who come to the workshops are at all stages of illness and treatment, but they are able to leave the house. If someone is very ill she can still participate with the At Home Self Help materials or the online instruction. She can then attend a workshop at a later date when she feels better. FINDING LOOK GOOD FEEL BETTER PROGRAMS Oncology nurses can get more information about this remarkable program 2 ways: Visit their website at http:// lookgoodfeelbetter.org, where the Program Finder requires only a zip code to produce a list of all nearby programs; or call their toll free phone number, 800-395-LOOK (5665), to speak with an American Cancer Society specialist who can help find programs and register participants. Oncology nurses interested in starting a Look Good Feel Better program in their community or facility can contact their local American Cancer Society chapter for help with bringing the necessary resources together. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

www.OncologyNurseAdvisor.com • JULY/AUGUST 2017 • ONCOLOGY NURSE ADVISOR 35

FEATURE | Oncology Nursing

Understanding Your Patient: Keys to Successful Outcomes Identifying which archetypical profile fits your patient can help oncology nurses individualize support and education needs to their patients.

Changing trends and new therapies are redefining the nurse-patient relationship.

CAROL BLECHER, MS, RN, AOCN, APNC, CBCN

ncology nurses have seen medical advances shift the prognosis of cancer from a death sentence to a chronic disease. If you have been on the front lines of cancer treatment long enough, you have seen the emphasis on surgery and radiation evolve into an emphasis on chemotherapy and, most recently, to novel therapies such as targeted treatment and immunotherapy. Some of the brightest minds in research are dedicating their time to the development and testing of medicinal compounds that could one day mean a cure for these now chronic diseases. Due to this paradigm shift, our roles as oncology nurses have changed as well. When treatment was relegated to chemotherapy for all, understanding the needs and proclivities of each patient was not particularly important. We cared for them and tried to help them through their treatment experiences, but in reality every patient was treated similarly.1-3 We simply needed to know the adverse effects of the chemotherapy agents and how to educate patients in the management of those effects. Today, understanding the specific characteristics that affect the way patients interact with their treatment is crucial.2,4 A patient on an oral regimen needs a totally different type of support than one on chemotherapy, just as a child may need different support than an adult.3 Oncology nurses have to think about how to ensure that patients understand their treatment,

36 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017 • www.OncologyNurseAdvisor.com

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

• Easy-to-use medical calculators

• Downloadable patient fact sheets

• Comprehensive drug slideshows

Visit www.OncologyNurseAdvisor.com today.

FEATURE | Oncology Nursing methods of obtaining their medications, managing the health system and its processes, and ultimately, how to persist with this complex and expensive treatment.2 We need to assess people’s social situations, ie, who is available to help them, so they stay motivated and positive over the long term.2 We also need to learn about our patients’ long term goals for their lives, not just the short term goals, because many cancer treatments, especially hematologic agents, are pills that patients will take for the rest of their lives. As an advanced practice nurse and clinical educator at a cancer center, I have seen patients respond differently to the same treatment based solely on factors that we, their

As medical professionals, we need to educate patients about their condition, and in some cases, we may need to uneducate patients. nurses, can influence. Although some efforts go a long way toward promoting treatment success, such as ensuring our patients are taking their medication appropriately, assessing their current medication burden, and closely monitoring new patients during the first few weeks of treatment. Other practices require personalized attention to be effective.1,2,4 The most important part of our job as nurses is to identify individual patient factors that can influence adherence to treatment and adjust our care to meet the specific needs created by these unique characteristics.2 What does this look like in practice? In this article, I have outlined a few archetypal patient profiles, identified over the course of many years of working in oncology, and my suggestions for setting each patient up for treatment success. A NEW DIAGNOSIS

Nearly every week, I witness patients crumble under the weight of a new cancer diagnosis. Despite all of the safe and effective treatments on the market today, the word “cancer” remains a scary term, especially to those facing it for the first time. While adjusting emotionally to the reality of a new cancer diagnosis, patients are forced to make decisions about treatment options, some of which may continue for the rest of their lives. One of my patient’s daughters pulled me aside one day, and asked how long her mother would be on the oral treatment the physician had just prescribed. Instead of simply stating that her mother would probably be on the medication for the rest of her life, which would absolutely overwhelm a new

caretaker, I broke her mother’s treatment into steps. Often what our patients need is for us to simplify the information from their physicians, by dividing it into digestible pieces.4,5 RELAPSED/REFRACTORY DISEASE

Caring for a patient whose disease has relapsed or become refractory to a treatment and understanding how the patient is adjusting to the situation can be difficult. My patients who are beginning an oral medication after having undergone IV chemotherapy often do not understand how a pill could help their cancer. Several of my patients have been on a variety of treatments for ovarian carcinoma and are now starting oral therapies. One patient’s husband is very supportive and assumes the role of cheerleader. He is always with her when she comes for visits and monitors her medications closely. The patient remains upbeat and comes to visits beautifully coiffed and dressed. Another patient, however, lives alone and has no obvious support system. She comes to visits very quiet and looking sad. She is not responsive to most offers of support from the staff and states that she can manage this independently. Both patients are adherent to therapy and are responding to their third/fourth line of therapy. The characteristic these women have in common, along with other patients who have relapsed or refractory disease, is that they want to continue to live their lives. Patients returning to treatment after a failed first-line therapy have unique needs that are very different from the needs of treatment-naïve patients.2 These patients and their loved ones are experiencing high levels of stress, likely related to the recurrence of their disease and the need for further therapy.2 Although these patients may have focused on certain approaches and information during their initial diagnosis, they may now wish to secure more in-depth information about the disease in an effort to understand why their disease relapsed.2 We need to take all of these characteristics into consideration. As patients’ caregivers, our efforts include recognition and understanding of their anxiety, tailoring information based on their current needs, and the ability to engage a team of health care professionals, including social workers, to address the holistic needs that we as nurses are not always equipped to handle.2 NONADHERENCE

Identifying a patient who struggles with adherence can be a challenge and the barriers may not always be obvious. I had a patient who was illiterate, and he struggled to follow his at-home oral medication regimen because he could not read and comprehend the labels. I sat down with him, listened to

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his stories about his life, and assessed him for ways in which he could be helped. After taking the time to have a more indepth talk with this patient, I learned that if his pill container was filled when he was in the office, he would then take his medication correctly. Other issues with nonadherence include financial concerns.4 Several patients have recently told me that they could not afford their co-pays and therefore did not want to start the medications. A variety of resources, including foundations, advocacy groups, pharmaceutical assistance programs, etc, are available. Helping patients with overwhelmingly large co-pays obtain co-pay assistance is a vital role of the oncology care team.3,4 With emerging cancer therapies in the oncology arena, patients are now able to take oral medications at home.2,6 However, in many cases, this also means oncology nurses have less control over when, how, and even if, our patients take their medication.2,6 Nurses play a vital role in helping patients understand the importance of adherence and persistence. They are essential in helping identify the individual risk factors for each patient, including knowledge deficits regarding disease and medications, financial issues, lack of social support, fears regarding adverse effects, lack of effective communication between the patient and health care team, cultural issues, perception of benefits of the medication,

The more we understand about our patients, their needs, goals, and concerns, the better we can guide them to ensure treatment success. complexity of the regimen, patient depression/distress, and inadequate clinician follow-up.1,2,4 Many patients do not fully understand the implications of missing doses or discontinuing treatment, and they may need encouragement and a great deal of support and empathy to adhere to the treatment plan.2 Helping patients understand both their disease and their medications is of the utmost importance.2 Patients and their families must be assessed and counseled in an empathetic and culturally sensitive manner.2 The effectiveness of the social support system should also be evaluated. Some patients may live with people who are not able or willing to be supportive as they cope with their illness and medication management.2,4 A factor vital to patient education is an assessment of the family’s, caregiver’s, or significant other’s knowledge, ability, and desire to learn.2 The current knowledge base learning desire/ability of these people should be checked and validated frequently throughout the patient’s treatment course.2,3

In addition, many oncology drugs are only available through specialty pharmacies, so obtaining accurate insurance information becomes particularly important.6 Communication must be open to effectively navigate the process of obtaining the medication and adhering to the treatment regimen.2,7 Whenever a new regimen is started, the patient should be closely monitored, especially during the first couple of months, using coaching techniques, calendars, pill boxes, and pill counts to assure adherence.2,4 THE QUIET ONES

Some patients respond to a cancer diagnosis by shutting out the world. They may feel as if they have been given a death sentence and are now no longer a part of the world, or they might be distancing themselves from the diagnosis (“this is not really happening to me, and I am going to step aside and watch from the outside”). The quiet patient appears to listen to what you are saying, but the nurse as a health care professional dealing with this patient can see that the information is not being absorbed.2 Patients who do not have a caregiver to ask questions on their behalf may have difficulty articulating their thoughts and may miss the opportunity to fully understand their disease and treatment.4 Oftentimes the quiet patient is misinterpreted as being apathetic, angry, confused, or even disinterested. This patient may require psychosocial support before he or she can cope with the diagnosis and treatment plan.2 The first objective here would be to assess how the person handled/overcame other crises in their lives and how effective those tactics were. If this is a person who has always closed themselves off in time of crisis, then the health care team would need to determine how to support this patient while providing the information necessary for self-care during treatment.2 EDUCATED, OR OVER-EDUCATED

A number of years ago, I worked at a facility where patients thoroughly researched their diagnoses, and we would review all the information they brought to us. I currently tend to see patients with blood cancers that do not manifest until later in life and who are not as savvy on the Internet as younger generations; therefore, I do not see a large number of patients who are well-educated about their disease in my current environment. Many times the patient’s child or younger caregiver is the one who arrives for an appointment with printouts from medical websites detailing the symptoms or prognosis for the patient’s disease. Not only has medicine itself changed over the years, but our immediate access to information about medicine has Continues on page 41

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FEATURE | Breast Cancer

Treatment-Related Late Effects Identified in Some Survivors Deficits in balance, gait, and walking speed in patients treated with taxane chemotherapy were comparable to those of other fall-prone populations.

CIPN in breast cancer survivors treated with taxane-based chemotherapy was found to increase risk of falls.

BETTE WEINSTEIN KAPLAN

ecent research has found that only one chemotherapy treatment is necessary to launch a cascade of instability in a cancer survivor’s balance or gait, leading to an increased risk of falling while walking or even just standing. Importantly, the oncology team needs to be aware of this potential adverse effect because they may have to adjust medication as well as take additional steps to lower the patient’s risk of falls.1 Chemotherapy-induced peripheral neuropathy (CIPN) is known to cause nerve damage, resulting in a diminution of feeling in the hands and feet in as many as 60% of patients. Researchers from The Ohio State University and Mayo Clinic sought to describe the natural histories of patient-reported CIPN symptoms and functional impairments in patients with breast cancer receiving taxane-based chemotherapy. For the study, the researchers enrolled 33 patients (32 female and 1 male) with stage I-III breast cancer, average age 48 years. All participants were starting on taxane-based chemotherapy regimen. The study excluded patients who could not stand or walk without assistance, had a prior diagnosis of any type of neuropathy, and/ or were exposed to other medications known to cause neuropathy within the past year. Patients who had been exposed to other chemotherapy agents were eligible.1 Effects on balance and gait Patients’ standing balance, gait, and other outcomes were evaluated at 5 time points. The first assessment established a baseline before treatment began, the next 3

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were performed prior to each chemotherapy cycle, and the final evaluation occurred 1 to 3 months after the last infusion. To evaluate standing balance, patients participated in 30-second standing trials with their eyes closed. Gait evaluation required participants to walk along the clinic hallway as quickly as they could in 1-meter trials, twice. Speed was significant: a slower walking speed and shorter length of step are indicative of a cautious gait.1 Medial-lateral sway (side-to-side) was increased 28% after the first chemotherapy treatment. Subsequent sessions increased the movement to 48%. Walking speed was reduced by 5% after 3 chemotherapy cycles. The researchers noted that these symptoms were only statistically significant with taxane exposure; none of the subgroup analyses such as the effect of prior cyclophosphamide, doxorubicin, pegfilgrastim, or weekly paclitaxel treatment attained statistical significance.1 The researchers noted patients had a diminution in balance as well as reduced walking speed and decreased length of step as their taxane exposure increased. Motor and autonomic symptoms also became increasingly worse with cumulative taxane exposure, as well as patient-reported episodes of pain.1 Late Effects Worsening balance and gait did not stop when treatment was discontinued. An association between

survivors’ self-reported sensory symptoms and balance difficulties became evident only within 1 to 3 months after the conclusion of taxane therapy.1 The increased risk and incidence of falling after chemotherapy is a significant concern for long-term quality of life in cancer survivors. Compared with reports of elderly who are prone to falls, the balance deficits seen in this population were worse. Similarly, their reduced walking speed correlated with decreases seen in other fall-prone populations. Although taxane therapy negatively impacted balance, gait, motor, and autonomic symptoms, and worsened pain, participants’ fatigue did not worsen.1 Based on these results, oncology clinicians are advised to evaluate patients for diminished balance and gait, and seek input from physical therapists as part of patients’ posttreatment care. ■

Outcomes Success

unique needs, wants, goals, and concerns, the better we can guide them to ensure treatment success, regardless of their treatment type.2,4 I encourage my fellow oncology nurses to spend time getting to know their patients to determine what type of care they need. Is your patient returning to treatment after a period of remission and in need of emotional support? Or is your patient having trouble sticking to the oral medication regimen and needs someone to create a calendar or fill their pill box? The profiles described here are just a starting point. I hope they encourage you to recognize and appreciate the individualized nature of modern cancer care, as well as the need for nurses to take on the challenge of oral regimen adherence. ■

Continued from page 39

also changed.1,2 As medical professionals, we need to educate patients about their condition, and in some cases, we may need to uneducate patients and their caregivers, explaining why information they heard or read may not apply to them.1 My first reaction is to advise the people involved what many of us probably tell our patients: “Take everything you read with a grain of salt.” Although the information they are getting is not necessarily wrong, it may not apply directly to their situation. We also have a responsibility to direct people to appropriate and reliable websites. It is our responsibility to encourage patients to be advocates for their own health, while still trusting in the training and experience of their health care team.1

Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Monfort SM, Pan X, Patrick R, et al. Gait, balance, and patient-reported outcomes during taxane-based chemotherapy in early-stage breast cancer patients. Breast Cancer Res Treat. 2017;164(1);69–77. doi:10.1007/ s10549-017-4230-8

Carol Blecher specializes in hematology/oncology at Trinitas Regional Medical Center, Trinitas Comprehensive Cancer Center in Elizabeth, New Jersey.

Conclusion

One certainty of medicine is that it will continue to evolve, thereby continuing to shift the job descriptions for oncology nurses.2 The more we understand about our patients, their

REFERENCES The references are included in the online version of this article, available through this quick link: http://bit.ly/2tE7vAu.

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JOURNAL REVIEW

olapitant, a selective and long-acting neurokinin-1 (NK-1) receptor antagonist, may provide adult cancer patients with significant benefits beyond those of previously approved NK-1 receptor antagonists, according to Bernardo Leon Rapoport, MD, The Medical Oncology Centre of Rosebank in Johannesburg, South Africa. He is the author of a review article published in Cancer Management and Research that suggests this agent can help combat delayed chemotherapyinduced nausea and vomiting (CINV), improve quality of life, and provide other benefits for patients.1 CINV commonly occurs during the acute phase and during the delayed phase. However, patients often are not in direct contact with their oncology care team during the delayed phase; this is where significant improvement is needed in the clinical management of CINV. THE STUDY NK-1 receptor antagonists can help prevent acute and delayed CINV in patients treated with highly emetogenic chemotherapy (HEC) and moderately emetogenic chemotherapy (MEC). These agents are used in combination with a 5-hydroxytryptamine 3 receptor antagonist and dexamethasone. Dr Rapoport examined the differential pharmacology and clinical utility of rolapitant in preventing CINV compared with other NK-1 receptor antagonists. Rolapitant was granted approval for the management of delayed CINV by

Rolapitant Effective in Relieving Delayed CINV John Schieszer, MA

the US Food and Drug Administration (FDA) in September 2015. In a phase 3 trial, rolapitant 180 mg demonstrated statistical superiority compared with active control (5-HT3 receptor antagonist plus dexamethasone) in the delayed phase of CINV. The trial involved 1332 patients receiving moderately emetogenic chemotherapy regimens, including anthracycline/cyclophosphamide combinations, carboplatin, irinotecan, pemetrexed, oxaliplatin, and doxorubicin. WHAT WAS LEARNED? Data from phase 3 trials have shown that rolapitant may significantly improve quality of life in patients receiving either HEC or MEC. In addition, the agent may help with patient nonadherence because of its single oral administration prior to chemotherapy. Rolapitant has a long half-life (plasma half-life of approximately 7 days) and so it provides longer sustained efficacy than

other NK-1 receptor antagonists. It is associated with only mild-to-moderate adverse effects based on several clinical trials with thousands of cancer patients. Cindy Samborski, MSN, MHA, RN, a clinical research educator at Roswell Park Cancer Institute, Buffalo, New York, said the oncology nurse’s role is to thoroughly understand CINV, educate the patient, be proactive in prevention, identify early onset, and suggest interventions. “The importance of this issue can directly impact outcome of treatment for the patient, compliance with therapy, and with receiving the correct strength of chemotherapy doses,” Ms Samborski told Oncology Nurse Advisor. “The nurse has the ability to improve a patient’s quality of life through education and assessment, and medications.” IMPLICATIONS FOR NURSES Dr Rapoport writes that acute CINV has been improved disproportionately to date compared with delayed CINV, particularly among those patients who receive HEC. Medical oncologist Elizabeth Wulff-Burchfield, MD, Vanderbilt University Medical Center, Nashville, Tennessee, said oncology nurses’ role in addressing this deficit is pivotal. Dr Wulff-Burchfield said the current review raises a number of important points, including that a layered approach is most effective for these medications when managing delayed CINV. “The chemotherapy counseling and consent process that takes place between patients and oncologists often Continues on page 48

The current review raises a number of important points, including that a layered approach is most effective for these medications when managing delayed CINV. 42 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017 • www.OncologyNurseAdvisor.com

RADIATION & YOUR PATIENT

Radiotherapy Outcomes Improved With Lower Doses, More Fractions Bryant Furlow In hyperfractionated radiotherapy, a patient’s total radiation dose is split into lower-dose fractions that are delivered in quick sequence, more frequently than once daily. The goal of hyperfractionation is to reduce toxicity while improving tumor control. The total dose is often delivered over a period of days or weeks, comparable to conventional radiotherapy regimens, with the goal of exceeding the total dose delivered in standard treatment.1,2 However, hyperfractionation can also be used to deliver a similar total dose in an overall shorter time period.3

he use of hyperfractionation has been explored for decades, with mixed results.2 In patients with small-cell lung carcinoma (SCLC), twice-daily radiation (1.5 Gy fractions, for total dose of 45 Gy) with concurrent chemotherapy has been tied to longer survival times than 45 to 72 Gy total doses delivered in 1.8 or 2.0 Gy fractions.3 In this study, hyperfractionation cut the total duration of radiation therapy from a median of 50 days to 22 days.3 Treatment in an academic cancer center was associated with a higher likelihood of undergoing hyperfractionated chemoradiation, and in multivariate analyses both treatment at an academic center and hyperfractionated treatment were associated with improved survival times (hazard ratio [HR] 0.88 and 0.92, respectively; P <.001 and P =.008).3 “The adoption of BID radiation remains very limited, but is more commonly utilized in the academic setting,” the study investigators concluded.3 “In this hospital-based study, BID fractionation was associated with improved survival over once daily fractionation, even at doses [greater than or equal to] 60 Gy.” A separate study published in 2015 found that 10-year locoregional control rates for head and neck cancers (which experiences slower tumor cell proliferation and repopulation than SCLC) were superior in patients who had undergone hyperfractionated radiotherapy plus concurrent mitomycin C/ fluorouracil-5 (5-FU) chemotherapy, compared with radiation therapy alone (38% vs 26%).4 Overall survival (OS) rates were 39% for hyperfractionated chemoradiation vs 30% for hyperfractionated radiation therapy alone.4 In multivariate analysis, locoregional control following hyperfractionated

chemoradiation outperformed hyperfractionated radiation therapy alone (hazard ratio [HR] 0.6; 95% CI, 0.5-0.8; P =.002).4 However, subgroup analyses suggested that this benefit might have been limited to patients with oropharyngeal cancers, as patients with hypopharyngeal or oral cavity tumors did not see comparable, statistically significant improvements in locoregional control.4 In patients with SCLC, longer duration of hyperfractionated chemoradiation might modestly affect survival time (HR 1.08; 95% CI, 1.01-1.15).5

Hyperfractionation cut the duration of therapy from a median of 50 days to 22 days. A new study reported at the European Cancer Congress earlier this year bolstered the case that hyperfractionated chemoradiation benefits patients with advanced head and neck cancers; the research team found that adding twice daily radiotherapy to chemotherapy improves mortality risk by 20% and cuts the risk of tumor progression by 23% in patients with advanced head and neck cancer, compared with standard once daily radiation treatment with chemotherapy.1 The researchers conducted a network meta-analysis of data from 117 clinical trials representing 28,804 patients with advanced head and neck cancer. A total of 16 treatment strategies were compared in patients with squamous cell carcinoma. More than 19,000 patients died and 20,586 saw tumor progression.1 “There are a number of new treatments that have shown promise in head and neck cancer trials,” noted

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RADIATION & YOUR PATIENT co-investigator Claire Petit, MD, of the Gustave Roussy Cancer Center in Paris, France. “This large study has enabled us to compare several of these treatments to see which is best overall in terms of reducing mortality.” ASTRO’s new radiation therapy guideline for oropharyngeal cancer includes twice daily hyperfractionation as a definitive radiotherapy treatment option in patients with stage IV A-B disease, patients with T3N1 disease who are not candidates for concurrent chemoradiation, and patients with T1N1 or T2 disease deemed to be at high risk of tumor recurrence.6 Dr Petit and her co-investigators cautioned that it is too soon to advocate widespread clinical adoption of hyperfractionated radiation therapy in these patients because they did not analyze toxicity profiles during or after treatment.1 Concerns about safety, along with logistical challenges, have prevented widespread adoption of twice daily chemoradiation, but international randomized clinical trials found that once daily radiotherapy did not yield a better toxicity or survival profile than twice daily treatment in 547 patients with early-stage SCLC between 2008 and 2013.7 At a median follow-up of 45 months, median OS was 30 months vs 25 months for twice daily intensitymodulated radiotherapy (IMRT; HR

1.17; 95% CI, 0.95-1.45; P =.15, not significant).7 Grade 3 to 4 neutropenia was more frequent in patients in the BID study arm (74% vs 65%; P =.03).7 But toxicity rates were otherwise comparable between patients in the oncedaily and twice-daily radiation therapy study arms, the researchers reported.7 More research is needed to determine whether safety is similarly comparable to standard regimens in patients with head and neck cancers. ■

in small-cell lung cancer and its impact on survival. J Thorac Oncol. 2015;10(12):1770-1775. 4. Budach V, Stromberger C, Poettgen C, et al. Hyperfractionated accelerated radiation therapy (HART) of 70.6 Gy with concurrent 5-FU/mitomycin C is superior to HART of 77.6 Gy alone in locally advanced head and neck cancer: long-term results of the ARO 95-06 randomized phase III trial. Int J Radiat Oncol Biol Phys. 2015;91(5):916-924. 5. Morimoto M, Okishio K, Akira M, et al. Duration of twice-daily thoracic radiotherapy and time from the start of any treatment

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

to the end of chest irradiation as significant predictors of outcomes in limited-disease small-cell lung cancer. Clin

REFERENCES 1. ECCO2017 NEWS: Twice-daily radiation

Lung Cancer. 2017;18(2):e117-e127. 6. New ASTRO guideline establishes standard

therapy cuts deaths from head and neck

of care for curative treatment of oropharyn-

cancer [news release]. Amsterdam, The

geal cancer with radiation therapy [news

Netherlands: European CanCer Organisation;

release]. Arlington, VA: American Society

January 26, 2017. https://www.eccocongress.

for Radiation Oncology; April 17, 2017.

org/Global/News/ECCO2017-News/2017/01/

https://www.astro.org/News-and-

ECCO2017-NEWS-Twice-daily-radiation-

Publications/News-and-Media-Center/

therapy-cuts-deaths-from-head-and-neck-

News-Releases/2017/New-ASTRO-guideline-

cancer. Accessed July 31, 2017.

establishes-standard-of-care-for-curative-

2. Fu KK, Jajak TF, Trotti A, et al. A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfractionation

treatment-of-oropharyngeal-cancer-withradiation-therapy/. Accessed July 31, 2017. 7. Faivre-Finn C, Snee M, Ashcroft L, et al.

and two variants of accelerated fractionation

CONVERT: an international randomised trial

to standard-fractionation r adiotherapy for

of concurrent chemo-radiotherapy (cCTRT)

head-and-neck squamous cell carcinomas:

comparing twice-daily (BD) and once-daily

first report of the RTOG 9003. Int J Radiat Oncol

(OD) radiotherapy schedules in patients with

Biol Phys. 2000;48(1):7-16.

limited stage small cell lung cancer (LS-SCLC)

3. Schreiber D, Wong AT, Schwartz D, Rineer J. Utilization of hyperfractionated radiation

Let us answer your questions! E-mail us at editor.ona@haymarketmedia.com with your general questions for our expert Advisor Forum and your drug-related questions for Ask a Pharmacist! 44 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017 • www.OncologyNurseAdvisor.com

and good performance status (PS). J Clin Oncol. 2016;34(suppl):abstr8504.

COMMUNICATION CHALLENGES

The Great Cancer Masquerade: Grief as Anxiety, Control, Anger Ann J. Brady, MSN, RN-BC CASES

Grief as anxiety The first situation was in

In all 3 situations, what seemed obvious to us caregivers was not obvious to the family.

ome people insist it’s superstitious to believe the old saying that trouble comes in threes. Others think it’s hocus pocus, nonscientific, absurd. But anecdotally, it seems to happen that way. Bad things come in threes. Death comes in threes. Complicated family or patient interactions come in threes. That’s exactly what happened recently. Three complicated patient/family situations played out in the days before each patient died. In all 3 situations, what seemed obvious to us caregivers was not obvious to the family. All 3 patients were dying and all 3 were surrounded by family who could not see what we did for them. And all 3 created stressful interactions between the nurses and the families.

some ways the most difficult because Brad, the patient’s husband of 30 years, was an earnest and sweet caregiver. His wife had had multiple readmissions; each time she was weaker, but his hope endured. She had stage IV cancer and had been through several lines of therapy and was so weakened she could not tolerate more. But her doctor mentioned that if she was able to get a little stronger there was another treatment option she could try. Brad grabbed hold of that lifeline with everything he had. With the slightest change in her condition — confusion, dehydration, infections — he rushed her to the ER. During each admission, the option of hospice was offered, but each time they refused, convinced she would get strong enough for that last chemo. On her final admission, her condition deteriorated so fast that Brad could not seem to register how poorly she was doing. He was hypervigilant to the smallest details and repeatedly asked the same questions: “She’s snoring, is that ok?” “She’s been moving her legs around, what do you think that means?” He’d stand at the nurse’s station and sweetly say, “I don’t want to bother anyone, I just have one question.” Brad was endearing and annoying at the same time. He wanted her to live so desperately. But his constant need for reassurance was exhausting for the staff. Grief as control The distraught family of the second patient responded to the situation with confrontation, which quickly led to frustration for the people caring for Susan. In spite of good clinical nursing, the family

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COMMUNICATION CHALLENGES

We need a care plan for ourselves in these situations. One way to provide that is by debriefing.

constantly questioned everything we did. This family was a few doors down from Brad and his dying wife, and the contrast was stark. Susan had been estranged from her family for many years, but when she was admitted to the hospital they rushed to her bedside. They had known she was ill but not how far her cancer had progressed. We knew they were in shock and worked to provide support for them while keeping our focus on Susan. She was obtunded when she came into the ER and was immediately placed on a ventilator. By the time the family arrived, she was too fragile to consider transferring her home on hospice. With no treatment options and in complete organ failure, she was terminally extubated per her POLST instructions and transferred to the oncology unit to die. Her family also held a bedside vigil and someone was there all the time. When she survived for several days the family began to think she might rally enough to interact with them. Susan required a morphine drip, which the nurses titrated for comfort. The goal of keeping Susan comfortable was explained to the family, but each time the rate was adjusted upward they became more confrontational. They believed we were trying to speed up the dying process. They wanted to believe she could pull through even as she was actively dying. Grief as anger The third family struggled with the rapid progression of their loved one’s disease. Elise was feeling poorly on the day of her wedding anniversary but was able to participate in a family celebration. Only 2 days later, she developed severe abdominal pain and was hospitalized. Almost as soon as her pancreatic cancer was diagnosed she progressed to respiratory failure. Extended family and friends came to visit but could not believe she was in the ICU when she had been celebrating only a week earlier. Surely, we were wrong when we said she was dying. They, too, questioned everything we did, but instead of being just verbally confrontational they were angry and physically threatening. At one point, security had to intervene (code gray) when her son began

shouting at the nurses. As the reality of what was happening with Elise settled over the family, they calmed down. Yet barbed comments continued to be made about what had happened to Elise, blaming health care workers who delivered the bad news as if they had caused her condition. DISCUSSION None of these situations are unusual for oncology nurses. We see a myriad of family reactions to poor prognosis and impending death. Grief masquerades in ways that can be confusing. Having 3 complicated situations back-to-back created and aggravated the stress level of the nurses on the oncology unit. None of us could change what was happening with the patients, and our interactions with each of these families presented challenges. What we could do was acknowledge how difficult it was, provide support for the families, and most importantly provide support for each other. It is easy to wade into messy situations and inadvertently make them messier. It is easy to be drawn into complaining about difficult families, to retell details of the interactions, and to get frustrated. How we support each other through these challenges is something we can anticipate and control. We need a care plan for ourselves in these situations. One way to provide that is by debriefing. Too often we move on to caring for our next patient and the anecdotes of those difficult family dynamics become almost folklore — “Remember that family we had to call a code gray on?” “Remember how Brad used to drive us all crazy?” Debriefing does not have to be formal. And it can start as soon as we recognize that we are in a stressful patient situation. Rather than moving on it makes sense sometimes to stay in that moment, to ask ourselves what we might do differently next time. What worked, and what didn’t work. What we want to prevent is frustration masquerading as burnout. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

46 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017 • www.OncologyNurseAdvisor.com

Text Message System Relies on Common AYA Behavior to Enhance Survivorship Care Bette Weinstein Kaplan

here is one type of text messaging that some teens and young adults are actually encouraged to use: to participate in a system that improves care for adolescent and young adult (AYA) survivors of childhood cancer. More young people are surviving childhood cancers; the long-term childhood cancer survival rate is now higher than 83%.1 Thus, there is an increasingly large number of AYAs who are at risk for developing late effects from their cancer treatment.

LATE EFFECT SCREENING These sequelae can be physical, psychological, or social. Chronic or late effects occur in approximately 65% of childhood cancer survivors, with approximately 30% of late effects having fatal consequences.1 The Institute of Medicine recommends life-long surveillance, prevention, and treatment of late effects as a component of survivorship care in this patient group. The survivorship care clinician should be knowledgeable about a patient’s cancer treatment history, conduct a physical examination, order laboratory tests and imaging studies, and make referrals to specialists based on the patient’s risk for late effects. However, this course of events does not occur for most cancer survivors, and the number of survivors who receive the recommended medical follow-up is negatively

correlated with the number of years since diagnosis.1 This could be a real danger. Some of the late effects, such as cardiac dysfunction resulting from chemotherapy, may be asymptomatic initially, and reduction of long-term morbidity and mortality depends on early detection and treatment. Several age-specific barriers hinder ensuring early adoption of late-effect

The 2-way system allows clinicians to send programmed messages and to receive responses. screening in AYA survivors. For example, the health care system can be fragmented and expensive. Clinicians may not be comfortable providing survivorship care for AYA survivors, or even know how to do so. In addition, survivors may not understand the problem posed by improper health behavior and the negative potential for late effects. AYA survivors of childhood cancers are ready to move on and accept the responsibilities of work and family. Visiting a health care provider when there is no obvious need to do so is not high on anyone’s list.

ESTABLISHED BEHAVIORS So how can clinicians alert these young people to their special needs in an age-appropriate way that would be acceptable to them? The answer is text messaging. The behavior appears to come naturally to them, is one they seem to be constantly engaged in, and will not differentiate cancer survivors from their peers. What young person does not have a mobile phone? They are ubiquitous. Of children aged 12 to 13 years, 68% use a cell phone; of those aged 14 to 17 years, 83% use a cell phone; and among those aged 18 to 24 years, 97% own a cell phone. Text messaging is already used to send appointment reminders and other health-related messages to patients of all ages. Reminders to parents using text messaging led to increased rates of immunizations in infants and adolescents, and patients on antiretroviral therapy demonstrate better viral suppression when they receive weekly text messages reminding them of their next treatment. AN INTERACTIVE MESSAGE SYSTEM Researchers in California designed a text messaging system for AYA survivors of childhood cancers in the greater Los Angeles area. They enlisted the collaboration of the University of California Los Angeles (UCLA) Center

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ISSUES IN CANCER SURVIVORSHIP for Embedded Network Sensing (CENS). Established in 2002, CENS is a research enterprise led by UCLA in partnership with 5 other universities in southern California. “CENS explores the fundamental properties of embedded networked sensing systems to develop new technologies and investigate their role in health care and other systems education properties.”2 The objectives for the pilot study were to “develop the text messaging system for sending programmed lateeffect screening reminders and tailored suggestions for community resources; examine the acceptability, feasibility, and usability of the text messaging system for AYA survivors; and refine the text messaging system using the qualitative data collected for use in a future intervention study.”1 The 2-way system allows clinicians to send programmed text messages to their patients, and to receive responses from them. The innovative internet interface facilitates many functions, including program enrollment. The system sends AYA survivors programmed reminders

to schedule appointments for screening for late effects of their cancer treatment, and also sends reminders of the appointments. Messages are customized to each survivor based on their treatment history and risks. For example, if a survivor had received a particular chemotherapy agent, the text message would remind the patient to also schedule appropriate tests, such as a CBC to check for treatment-related leukemia, and include the addresses and phone numbers of the office and laboratory. Once the patient scheduled his or her appointment, the information is in the system; reminders and pretest instructions are sent 2 days before, 1 day before, and on the morning of the appointment. The program also includes a followup message that surveys survivors about their appointment and experience with the clinician. Several modifications have been incorporated since the system was first designed, such as providing survivors with information on available resources in their communities.

OFF TO A GOOD START The researchers used a series of focus groups to evaluate the system. The pilot study participants reported that the text messaging system was a good way for them to communicate with their health care team, coordinate and receive reminders for appointments, and locate medical and community resources. They even suggested another use for the system: survivor social networks. Text messaging systems are proven to have the potential to improve survivorship care. ■

Journal Review

synthesize this knowledge and empower them to act on it,” explained Dr Wulff-Burchfield. Currently, new cancer treatments are being approved at a record pace and Dr Wulff-Burchfield said this creates an interesting dynamic whereby oncology providers are feeling more invested than ever in both the value of cancer therapy as well as the impact that cancer and treatments can have on the patient and caregiver. She said oncology nurses are uniquely gifted at helping patients and oncologists strike a balance between the two goals. “I believe that the field of oncology is entering an era in which supportive care, symptom control, and global

quality of life are considered as essential to cancer care as the cancer treatments themselves. At the same time, we are also living in an age of unparalleled discovery for cancer therapies, extending the lives of patients while also creating uncharted territory concerning treatment-related side effects,” said Dr Wulff-Burchfield. ■

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covers a wide array of possible consequences from treatment, both positive and negative. Oncology nurses, both in the clinic and in the infusion room, can provide valuable guidance to patients and caregivers by reiterating the most pertinent symptoms and illustrating a practical management algorithm,” Dr Wulff-Burchfield told Oncology Nurse Advisor. She said the old saying of “forewarned is forearmed” absolutely holds true for symptom management in this clinical setting. “Oncology nurses are often the people who help patients and caregivers

48 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017 • www.OncologyNurseAdvisor.com

Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Casillas J, Goyal A, Bryman J, et al. Development of a text messaging system to improve receipt of survivorship care in adolescent and young adult survivors of childhood cancer [published online March 31, 2017]. J Cancer Surviv. doi:10.1007/s11764-017-0609-0 2. UCLA center for embedded networked sensing (CENS). AUVAC web site. http://auvac.org/ people-organizations/view/386. Accessed August 1, 2017.

John Schieszer is a medical writer based in Seattle, Washington. REFERENCE 1. Rapoport BL. Differential pharmacology and clinical utility of rolapitant in chemotherapyinduced nausea and vomiting. Cancer Manag Res. 2017:9;41-50.

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n 1972, 3 members of a nascent but growing movement to establish homosexuality as a sexual orientation minority accorded all the rights guaranteed by the US Constitution were provided the opportunity to stand before the American Psychiatric Association (APA). These activists petitioned the APA to remove homosexuality as a diagnostic category of mental illness from the Diagnostic and Statistical Manual of Mental Disorders (DSM). Fifty-eight percent of APA members voted in favor, an event historically known as the first landmark, professional and national decision for gay rights. With this, the progress of gay rights had officially begun.1 This history is timely in the current political narrative and atmosphere. The lesbian, gay, bisexual, and transgender (LGBT) community, which spans all races, ethnicities, nationalities, cultures, socio-economic statuses, and regions of the United States and represents 3% to 12% of the population,2 has been the focus of minimal and limited research, particularly related to cancer. Despite inclusion of LGBT communities in the 2020 US Blueprint of National Health Goals list of minorities experiencing health care disparities and inequities,3 the relationship of the medical professional with the LGBT person affected by cancer has not always been an inclusive and friendly one. Many LGBT patients with cancer, especially older gay men and women, report overt or covert discrimination or concerns of compromised care

Gay Men and the Stigma of a Cancer Diagnosis William Goeren, MS, LCSW-R, OSW-C, ACSW

in regard to their experiences with medical providers. The results of these experiences are explored further in the Minority Stress Model, which states that the interplay of social exclusion and discrimination, in combination with limited resources, expectations of rejection, nondisclosure, and stigma of cancer, can impact health behaviors, some of which have been linked to cancer incidence.4

GAY MEN AND CANCER The gay man with cancer brings a history of gay rights and health care disparity influences with him into the oncology office. This history includes his coming out to himself, his family, and society; his relationship with the gay community; his connection to HIV/AIDS treatment or prevention; discrimination and homophobia as a gay man; and a history of negative and positive interactions with medical providers. Research has shown that gay men, in general, are at higher risks for certain types of cancers, including lung, anal, colon, and esophageal as a result of higher rates of health risk behaviors including smoking, substance and alcohol use, lack of exercise, and psychological distress as well as experiencing prejudice, discrimination, or stigma in the process of seeking health care services.5 In addition, incidence of anal and oral human papillomavirus (HPV) infections are higher in gay men compared with their heterosexual counterparts. HIV-positive gay men have fewer HIV-related cancers due to the advent of antiretroviral treatment. However, HIV-positive gay men now have a 30% to 40% chance of developing a nonHIV-related cancer in their lifetimes, the cause of which is less understood. Those cancers include: Hodgkin disease (10× higher risk), anal cancer (50× higher risk), lung cancer (7× higher risk), and testicular germ cell cancer (6× higher risk).6 Many older gay men have often seen significant and multiple losses of

The gay man with cancer brings a history of gay rights and health care disparity influences with him into the oncology office. www.OncologyNurseAdvisor.com • JULY/AUGUST 2017 • ONCOLOGY NURSE ADVISOR 49

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community due to HIV/AIDS. Many are also less likely to be partnered or married but a percentage are living as long-term, HIV-survivors. HIV/AIDS as a comorbidity to a cancer diagnosis often impacts the patient-provider relationship, leading to additional health care fragmentation; poor communication between the patient with HIV and the oncology care team; and increased frustration, distress, and anxiety. Both HIV-negative and HIV-positive gay men often experience cancer as yet another stigma, resulting in further isolation, even within the gay male community, as well as poor psychological and emotional well-being. MEDICAL ISSUES

Older gay men often do not disclose their orientation to their oncologists. They tend to believe their sexual orientation was not important to their care team, they were not asked about it, or questions related to sexual orientation were not in the intake material. Nondisclosure results in poorer health care and less attention toward disease prevention, including appropriate tests and scans. Male-identified cancers — prostate, testicular, and penile — hold particular relevance to gay men in contrast to their heterosexual correlates due to sexual lifestyles impacting health care and treatment discussions. Research focused on the gay male experience with prostate cancer has noted that the essential responsibility falls proportionately on the health care team and the institution to create a safe environment for the gay man to review and discuss the significant impact of prostate cancer treatment on life style, including psychological and sexual well-being.7 CULTURALLY SENSITIVE CARE

The Gay and Lesbian Medical Association (GLMA) identified 10

areas essential for gay men to review in concert with their medical care team. Oncology nurses should be aware of these areas and encourage gay male patients to discuss them with their health care team: • Sexual orientation in regard to overall health and health care • HIV/AIDS, safe sex practices, and risk factors specific to the patient; • Hepatitis, including history of vaccination, exposure, infection, and treatment; • Diet and exercise, overall fitness, and potential body image concerns; • Substance and alcohol use/abuse; • Depression/anxiety, particularly with patients at higher risk for suicide (eg, adolescents, young adults) and those who remain in the closet; • Sexually transmitted diseases (STDs); • Screening for prostate, testicular, anal, and colon cancers; • Tobacco use and risk for tobaccorelated health problems; • HPV infection and risky behaviors.8

• Use resources and referrals that are LGBT inclusive; • Provide access to channels for registering concerns and complaints of homophobia, discrimination, or poor care; • Ongoing participation in HIV/AIDS awareness and training, especially as it relates to cancer. William Goeren is director of Clinical Programs at CancerCare. REFERENCES 1. The history of psychiatry and homosexuality. LGBT Mental Health Syllabus website. http:// www.aglp.org/gap/1_history/. Accessed July 31, 2017. 2. Quinn GP, Sanchez JA, Sutton SK, et al. Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. CA Cancer J Clin. 2015;65(5):384-400. 3. Healthy People 2020. Washington DC: US Dept of Health and Human Services, Office of Disease Prevention and Health Promotion; November 2010. ODPHP Publication No. B0132.

The oncology medical team, including physicians, oncology nurses, social workers, and support staff, can take the following steps to help gay men feel more confident in their health care, improve patient-provider communications, and build a strong relationship with these patients:

4. Boehmer U, Elk R, eds. Cancer and the LGBT Community. New York, NY: Springer; 2015:37-62. 5. Kamen C, Palesh O, Gerry AA, et al. Disparities in health risk behavior and psychological distress among gay versus heterosexual male cancer survivors. LGBT Health. 2014; 1(2):86-94. 6. The effect of cancer on the LGBT community.

• Place legal and institutional nondiscriminatory policies in public view; • Ensure intake materials, records, and assessments use gender-neutral and sexual-orientation friendly language; • Provide health care publications and patient materials that are LGBT sensitive; • Attend cultural competency training and formal education on working with LGBT patients;

50 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2017 • www.OncologyNurseAdvisor.com

New York, NY: The LGBT Cancer Project; 2007. 7. Lee TK, Handy AB, Kwan W, et al. Impact of prostate cancer treatment on the sexual quality of life of men-who-have-sex-withmen. J Sex Med. 2015;12(2):2378-2386. 8. Winn RJ. Ten things gay men should discuss with their healthcare provider. GLMA website. http://www.glma.org/index. cfm?fuseaction=Page.viewPage&pageID=690. Revised May 2012. Accessed July 31, 2017.