Oncology Nurse Advisor March/April 2020 by Haymarket Media

www.OncologyNurseAdvisor.com

March/April 2020

CANCER AND INFECTIOUS DISEASE JOURNAL REVIEW

Malnutrition, Inactivity May Be Hindering Clinical Trial Results

RADIATION & YOUR PATIENT

RadiotherapyAssociated OM or Trismus in Head and Neck Cancer

SARS-CoV-2 Pandemic: Protecting Patients, Nurses, and the Public

COMMUNICATION CHALLENGES

You Can if You Think You Can

THE TOTAL PATIENT

Individualized PFMT Improves Post Prostatectomy Outcomes

ISSUES IN CANCER SURVIVORSHIP

Helping Patients Cope With Treatment-Related Changes to Taste and Smell

ASK A PHARMACIST

PRSRT STD US POSTAGE PAID PONTIAC IL PERMIT #60

Managing AEs of Antiemetic Prophylaxis; Improving Iron Absorption

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.

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Editor Joyce Pagán editor.ona@haymarketmedia.com

Vice President, Oncology Business Development Henry Amato (646) 638-6096 henry.amato@haymarketmedia.com

Senior digital content editor Rick Maffei Oncology writer Susan Moench, PhD, PA-C Contributing writers Bryant Furlow Ann J. Brady, MSN, RN-BC, CHPN Bette Weinstein Kaplan Lisa A. Thompson, PharmD, BCOP Group creative director, Haymarket Medical Jennifer Dvoretz Graphic designer Vivian Chang Production editor Kim Daigneau

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HAYMARKET MEDIA Editorial Director, Haymarket Oncology Lauren Burke VP, Content; Medical Communications Kathleen Walsh Tulley

EDITORIAL BOARD Eucharia Borden, MSW, LCSW, OSW-C Cancer Support Community Philadelphia, Pennsylvania Jiajoyce R. Conway, DNP, CRNP, AOCNP Cancer Care Associates of York York, Pennsylvania Leah A. Scaramuzzo, MSN, RN-BC, AOCN Kalispell Regional Healthcare Kalispell, Montana Lisa A. Thompson, PharmD, BCOP Kaiser Permanente Colorado Rosemarie A. Tucci, RN, MSN, AOCN Lankenau Hospital Wynnewood, Pennsylvania

General Manager, Medical Communications Jim Burke, RPh

Production manager Brian Wask brian.wask@haymarketmedia.com

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Haymarket Media Inc Sales and Editorial offices 275 7th Avenue, 10th Floor, New York, NY 10001; (646) 638-6000 Subscriptions: www.OncologyNurseAdvisor.com/freesub Reprints: https://info.wrightsmedia.com/licensing-reprints-request Permissions: www.copyright.com Unless otherwise indicated, persons appearing in photographs are not the actual individuals mentioned in the articles. They appear for illustrative purposes only.

Oncology Nurse Advisor (ISSN 2154-350X), March/April 2020, Volume 11, Number 2. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. Copyright © 2020. 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.

www.OncologyNurseAdvisor.com • MARCH/APRIL 2020 • ONCOLOGY NURSE ADVISOR 1

CONTENTS 4

March/April 2020

IN THE NEWS • PPE Use During COVID-19: A Double Challenge • Nurse-Led Fast-Track Chemotherapy Clinic for Children Shows Promising Results • Optimal Nurse Staffing Levels at Ambulatory Cancer Care Centers: ONS Position Statement • Protocol Reduced MBIs, LCBIs Associated With Hematologic Cancer Treatments

• Hydroxyurea-Resistant/Intolerant PV Achieves Durable Response With Ruxolitinib • Supine-to-Prone Positioning Improved Lung Function in COVID-19-Related ARDS • Nonadherence to Oral Treatment for mCRPC May Be More Common Among Frail Patients

ONCOLOGY NURSE ADVISOR FORUM Patient Resources for Managing Financial Toxicity

FEATURES The Coronavirus SARS-CoV-2: 10 Myths About COVID-19 Natasha Priya Dyal, MD

21 FIND US ON

Do Patients With Cancer Need Specific Preventive Measures? John Schieszer

OncologyNurseAdvisor.com

facebook.com/OncologyNurseAdvisor

@ONAcom

linkedin.com/company/oncology-nurse-advisor

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www.OncologyNurseAdvisor.com

FEATURE ARTICLE Study Results Raise Concerns About Binge Drinking Among Cancer Survivors

Using data from the NHIS, researchers found correlations between alcohol use and various demographics among cancer survivors, including age, sex, race, and selfreported health. John Schieszer

JOURNAL REVIEW Malnutrition, Inactivity May Be Hindering Trial Results John Schieszer

RADIATION & YOUR PATIENT Radiotherapy-Associated OM or Trismus in Head and Neck Cancer Bryant Furlow

ISSUES IN CANCER SURVIVORSHIP Do Proton Pump Inhibitors Exacerbate the Cognitive Effects of Breast Cancer Treatment?

Proton pump inhibitors are used to control negative GI effects in patients receiving chemotherapy for breast cancer. But their availability as over-the-counter medications may be leading to overuse, making another common adverse effect worse. Bette Weinstein Kaplan

COMMUNICATION CHALLENGES You Can if You Think You Can Ann J. Brady, MSN, RN-BC, CHPN

FACT SHEET HIV Infection and Cancer Risk

The impact of the human immunodeficiency virus (HIV) on cancer risk. Inflammatory Breast Cancer

THE TOTAL PATIENT Individualized Pelvic Floor Muscle Training Improves Post Prostatectomy Outcomes Bette Weinstein Kaplan

A review of the symptoms, treatment, and prognosis statistics for inflammatory breast cancer PUBLISHERS’ ALLIANCE: DOVE PRESS Self-Reported Sleep Quality as Prognostic for Survival in Lung Cancer Patients

ISSUES IN CANCER SURVIVORSHIP Helping Patients Manage Treatment-Related Changes to Senses of Taste, Smell Bette Weinstein Kaplan

Cancer Management and Research

ASK A PHARMACIST Adverse Effects of Antiemetic Prophylaxis; Improving Iron Absorption Lisa A. Thompson, PharmD, BCOP

Retrospective analysis of a cohort of 404 patients with lung cancer reports of a correlation between sleep quality and survival among patients with the disease.

ON THE

WEB

www.OncologyNurseAdvisor.com • MARCH/APRIL 2020 • ONCOLOGY NURSE ADVISOR 3

IN THE NEWS PPE Use During COVID-19: A Double Challenge The coronavirus disease 2019 (COVID-19) pandemic is taking a toll on medical resources in the United States. As of March 30, 2020, a total of 140,904 cases have been reported to the Centers for Disease Control and Prevention from the 50 states, the District of Columbia, Puerto Rico, Guam, Northern Marianas, and the US Virgin Islands.1 With a growing number of cases, fears of the US hospital system being overwhelmed by the number of infected persons are being realized in several major cities throughout the country. What do we know about COVID-19? It is caused by severe acute respiratory syndrome coronavirus disease 2 (SARS-CoV-2), a novel coronavirus. Most patients present with fever, cough, and shortness of breath.2 Some anecdotal reports indicate that loss of smell and/or taste also may be early symptoms.3 The virus causes mild but prolonged disease; however, infected persons are contagious even when they have no signs or symptoms or don’t suspect they are infected. Factor in an incubation period that can extend beyond 14 days, and the conditions for widespread infection are optimal.2 hospitals has become how to prepare for the surge in patients, use supplies efficiently, and protect the medical workforce from becoming infected patients themselves. Many US hospitals are facing a serious shortage in personal protective equipment (PPE), which may expose clinicians throughout the hospital to a myriad of health threats as hospitals are forced to ration use of PPE across the facility. The Oncology Nursing Society (ONS) recognized that increased use and diminished manufacturing in other countries is straining the supply of PPE, forcing oncology nurses to make difficult choices.4 In response, ONS released interim guidelines for PPE use. The guidelines provide a tiered approach to options for use of gowns, gloves, and masks that is responsive to the severity of PPE shortage in different settings.4 “During a situation like the pandemic, the top priority shifts to protecting staff against the most immediate threat, COVID-19 infection,” ONS President Laura Fennimore, DNP, RN, NEA-BC, said in a statement. “These interim guidelines are temporary deviations from ONS’s typical PPE recommendations to make the most of the minimal resources available right now.”4 The interim guidelines, available at www.ons.org/covid-19-interim-guidelines, are intended for use in clinical practice and cancer treatment only in the event of PPE shortages from the COVID-19 pandemic. Nurses caring for patients with COVID-19 positive infections should follow infection prevention and PPE use recommendations from the Centers for Disease Control and Prevention.4 In addition, the 95,000 critical care beds currently available in US hospitals is not enough; conservative estimates suggest that more than twice that number are needed.5 Options hospitals can consider to meet that need include the conversion of single rooms to double rooms, expediting discharges, and slowing admission rates.5 Catheterization laboratories, lobbies, postop care units, and waiting rooms are areas that may be converted into patient care spaces. Despite some limitations, geographically separating patients with COVID-19 can help conserve medical supplies and reduce exposure to the virus, as well as protect vulnerable populations such as patients who are immunocompromised and those with cancer.5 References are included in the online version at http://bit.ly/onanews04201.

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What can oncology nurses expect to face as their facilities attempt to cope with the demands of caring for patients with COVID-19, and how will this affect how they care for patients with cancer? The challenge for US

Nurse-Led Fast-Track Chemotherapy Clinic for Children Shows Promising Results

Optimal Nurse Staffing Levels at Ambulatory Cancer Care Centers: ONS Position Statement

Based on the success of similar outpatient programs developed for adult patients with cancer, a pilot program was designed for the management of children with cancer currently receiving chemotherapy who were stable but required an urgent review. This program involved establishing an outpatient oncology fast-track clinic (OFTC) within The Children’s Cancer Centre, The Royal Children’s Hospital, Melbourne, Australia, that was led by senior oncology nurse specialists. A nurse-staffed telephone triage service was used to assess patient eligibility for the OFTC pathway. Patient outcomes, as well as patient/parent satisfaction, for 99 of the first 100 children prospectively assigned to receive care at the OFTC were compared with data derived retrospectively from medical records of a historical control group of 196 children treated with chemotherapy who presented to the ED between 9 am and 5 pm. This latter group of patients was determined to have met criterion used for referral to the OFTC. Key study findings included a shorter average time spent in the OFTC (2.2 hours) compared with the ED (5.11 hours). This finding was observed for patients admitted to the hospital (6.47 hours [ED] vs 4.18 hours [OFTC]) as well as for those not requiring hospital admission (3.4 hours [ED] vs 0.81 hour [OFTC]). Patients seen in the OFTC who were not admitted to the hospital underwent fewer interventions (n=1.7) than patients evaluated in the ED (n=2.1), although this difference did not reach statistical significance (P =.0828). In addition, fewer blood tubes were used per patient in the group receiving care at the OFTC (n=1.9) compared with the ED (n=3.2), even in the subgroup of patients admitted to the hospital from the OFTC (n=2.9; P =.0027). Fewer patients seen at the OFTC (6.4%) were admitted to the hospital for less than 1 day compared with those evaluated in the ED (16.3%), leading the study authors to comment that “the nurse-led clinic has also increased the accuracy of identifying which patients require hospital admissions.” Based on feedback provided through surveys administered prior to and following the receipt of care at the OFTC, approximately 90% or more of patients/parents expressed satisfaction with the initial triage assessment and advice provided to them over the telephone, as well as the care received at the OFTC.

Recognition of an ongoing transition of oncology care to the ambulatory setting, as well as the critically important role played by nurses in the provision of safe, quality outpatient oncology care, were 2 of the factors underlying the issuance of a position statement from the Oncology Nurse staffing can be Nursing Society (ONS) on ambulatory a multifaceted issue. oncology care treatment centers. ONS defined ambulatory oncology care settings as infusion centers where nonchemotherapy products (eg, blood products) and chemotherapy treatments are administered, as well as centers involving the outpatient administration of radiation therapy. Rooted in the conclusion that decisions related to the determination of appropriate nurse staffing can be complex, a central recommendation focused on the need to consider a number of patient-, personnel-, and institution-based variables to determine optimal nurse staffing levels at an ambulatory oncology care center. These variables included characteristics of the patient population, the type of treatment administered, details related to the current nursing and non-nursing staff, and logistical aspects of the institution at which ambulatory care is provided. ONS also called for the education of nurse managers at ambulatory oncology care centers regarding “the use of data in the determination of and advocacy for staffing that supports quality care,” the need for collaboration between professional nursing associations and other institutions/agencies in the academic, healthcare, and government sectors on nurse staffing initiatives, and “ongoing analysis of appropriate staffing models” for the ambulatory oncology care setting.

Read more at https://bit.ly/onanews04204

Read more at https://bit.ly/onanews04203

Protocol Reduced MBI-LCBIs Associated With Hematologic Cancer Treatments The rate of mucosal barrier injury (MBI) laboratory-confirmed blood stream infections (LCBIs) in patients who experience prolonged neutropenia associated with chemotherapy for hematologic cancers can be reduced through nurse and physician education and implementation of an oral care bundle.

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IN THE NEWS For PDSA cycle 3, the oral care bundle was redefined as a nurse-driven protocol, which did not require a physician order and ultimately improved the MBI incidence to 0.89 events per month. Plans to continue collecting monthly data are in place to ensure sustainability of the reduction in MBI-LCBI events. Read more at https://bit.ly/onanews04206

Hydroxyurea-Resistant/Intolerant PV Achieves Durable Response With Ruxolitinib Long-term follow-up of a phase 3 study comparing ruxolitinib with best available therapy in patients with polycythemia vera (PV) resistant to or intolerant of treatment with hydroxyurea revealed that complete hematologic remission was maintained at 256 RESPONSE showed weeks for approximately half of those 5-year OS of 91.9%. who achieved this study endpoint at 32 weeks following initiation of ruxolitinib. In this randomized, open-label clinical trial (RESPONSE; ClinicalTrials.gov Identifier: NCT01243944), 222 patients with PV previously treated with hydoxyurea were randomly assigned in a 1:1 ratio to receive either ruxolitinib, a JAK1 and JAK2 inhibitor, or best available therapy (ie, hydroxyurea, interferon or pegylated interferon, pipobroman, anagrelide, approved immunomodulators, or observation without pharmacological treatment). The primary composite study endpoint was the proportion of patients achieving both hematologic control without phlebotomy and a reduction of at least 35% in spleen size from baseline at 32 weeks of treatment. Complete hematologic remission at week 32, defined according to prespecified criteria for hematocrit level, and white blood cell and platelet counts, was a secondary endpoint of the study. In this long-term analysis of the study, completed after 5 years of follow-up, the primary composite response and hematologic complete remission were maintained at 256 weeks from initiation of treatment in 74% and 55% of patients who had achieved these respective endpoints at 32 weeks in the primary analysis. In the intention-to-treat analysis, which did not account for crossover, rates of 5-year OS were 91.9% and 91.0% for those treated with ruxolitinib and best available therapy, respectively. No new safety signals were observed on longterm follow-up, although 2 on-treatment deaths occurred in

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The Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) established 2 criteria to differentiate LCBIs from central line-associated bloodstream infections (CLABSIs): the identification of an organism with a known relationship to the oral cavity or gastrointestinal tract and MBI-compatible signs or symptoms in patients with either graft-versus-host disease associated with allogeneic stem cell transplantation or neutropenia. Mucosal barrier injury occurs during periods of prolonged neutropenia in patients receiving cytotoxic chemotherapy for hematologic malignancies. These events can lead to lifethreatening LCBIs caused by bacteria crossing compromised intestinal and mucosal barriers. A multidisciplinary team at the University of Virginia Health System (UVAHS) in Charlottesville sought to reduce the number of MBI-LCBI events at their facility. Using the CDC-NHSN criteria, retrospective reviews of 3 studies found that 71%, 44%, and 45% of CLABSI events met the criteria for MBI-LCBI. Therefore, the UVAHS team performed a single-institution retrospective analysis and found that the baseline number of events at the tertiary academic medical center was 1.1 per month. The team’s goal was to reduce the number of events per month in patients undergoing inpatient chemotherapy for hematologic malignancies by 25% by January 2019. Root cause analysis revealed that interventions focused on mucositis prevention, assessment, and treatment could potentially reduce MBI-LCBI events. Rates of MBI-LCBIs were tracked for a baseline cohort and across implementation of 3 Plan-Do-Study-Act (PDSA) cycles. For the first PDSA cycle, the intervention was nursing education and implementing mucositis treatment. A pre-education survey revealed that 27% of nurses reported a lack of understanding of MBI or no confidence in their assessment and management of patients with MBI. Posttest assessment after staff education showed an improvement to 89% of nurses expressing confidence in their ability to care for patients with mucositis. Incidence of MBI during this PDSA cycle remained stable. For PDSA cycle 2, the UVAHS team designed an oral care bundle as a preventive measure and designated it as a licensed independent practitioner (LIP) protocol that required an order upon admission. Initially, it achieved significant improvement as the MBI-LCBI rate went from 1.1 to 0.35 events per month. However, by the end of the cycle, electronic medical records showed a substantial decrease in LIP compliance with ordering the oral care intervention. Data revealed that the incidence of MBI-LCBI events was higher at the end of this cycle than at baseline.

the group receiving ruxolitinib, with 1 death, due to gastric adenocarcinoma, attributed to the study drug. The 2019 approval of ruxolitinib by the US Food and Drug Administration (FDA) for the treatment of patients with hydroxyurea-pretreated PV was supported by the results of the RESPONSE study. Read more at https://bit.ly/onanews04202

Supine-to-Prone Positioning Improved Lung Function in COVID-19-Related ARDS Observations of a small sample of patients with acute respiratory distress syndrome (ARDS) related to COVID-19 infection suggested that lung recruitability, which is related to the restoration of aeration in lung tissue using positive endexpiratory pressure (PEEP), was affected by body position. The goal of this study was to evaluate lung recruitability in patients with ARDS admitted to the intensive care unit with a confirmed COVID-19 infection and placed on invasive mechanical ventillation. Bedside assessment of lung recruitability was evaluated from data that were recorded in the medical charts over a 6-day period for 12 patients who were receiving treatment with PEEP at a single hospital in China. A key finding from this study was that there was a significant association between improved lung recruitability in those patients for whom body position was alternated between supine and prone compared with those who were not placed in a prone position. Read more at https://bit.ly/onanews04207

Nonadherence to Oral Treatment for mCRPC May Be More Common Among Frail Patients As use of oral antiandrogen agents (enzalutamide and abiraterone) becomes more common in the setting of prostate cancer, the risk of nonadherence to these treatments also has the potential to increase, particularly among older patients. G8 score shows need This observational prospective for intervention. cohort study enrolled 58 patients with metastatic castration-resistant prostate cancer (mCRPC) receiving oral antiandrogen therapy with enzalutamide (62%) or abiraterone (38%) at a single hospital in Italy. Adherence

to oral antiandrogen agents was assessed using a pill counting method conducted at each monthly appointment. In addition, self-assessments of adherence to these oral therapies were implemented for some patients (n=42) during the study. These included a modified version of the self-assessment Basel Assessment of Adherence Scale (BAAS), as well as patient clinical diaries, that were conducted/reviewed at clinical visits every 28 days. Clinical characteristics of the patient cohort included a median age of 76 years, and a median age-adjusted Charlson comorbidity score of 10. The median geriatric G8 score obtained using the G8 screening tool to identify patients most likely to benefit from a comprehensive geriatric assessment (G8 score of ≤14) was 14. More than half of patients were taking more than 3 drugs, and nearly three-quarters of patients had not received chemotherapy prior to treatment with abiraterone or enzalutamide. Most patients (81%) had a caregiver. Using the pill counting method to assess adherence, nonadherence rates of 4.8% and 6.2% were determined for the overall study period of 12 months and the first 3 months of the study, respectively. However, patient self-assessment by the BAAS tool revealed a medication nonadherence rate of only 1.3% for the overall study period, with “misperception of the need of the drug” and “forgetfulness” reported as the most common reasons for medication nonadherence. Rates of diary nonadherence were high: 38% for the overall study period and 36% during the first 3 months of the study. Discrepancies between medication nonadherence rates assessed through pill counting and patient reports “suggest that the patient tends to underestimate nonadherence and/ or that the self-assessed BAAS questionnaire probably cannot be considered a suitable tool in this setting,” the study authors concluded. Of note, on multivariate analysis, the geriatric G8 score (P =.005) was significantly associated with medication nonadherence for the overall study period. “This supports the importance of the identification of frail patients, even with an easy-to-use and quick screening tool as the G8 is, and that specific interventions should be directed to patients with a G8 score of ≤14,” the study authors commented. In addition, a significant association between low radiological response and medication nonadherence was observed (P =.03), leading the study authors to note that an awareness of the benefit of oral antiandrogen therapy may increase patient motivation to regularly take the drug. ■ Read more at https://bit.ly/onanews04205

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

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

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

Eucharia Borden, MSW, LCSW, OSW-C, senior director, Clinical Services, Cancer Support Community, Philadelphia, Pennsylvania.

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

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

PATIENT RESOURCES FOR MANAGING FINANCIAL TOXICITY My cancer center doesn’t have an expert dedicated to addressing the financial needs of our oncology patients. We’re getting more financial questions from patients and I’m not sure of the best resources to refer them to. Recently, someone even asked me about student loan deferment while undergoing treatment. Patients are often looking for explanations along with the next steps they should take. What are some trusted, key resources that I can refer patients to? — Name withheld on request Finances can be complicated, especially given that each person’s situation is unique; however, there are several places where patients can obtain more information. Here are a few key resources for cancer and finances: • Triage Cancer provides comprehensive information, such as a “Checklist to Minimize Financial Toxicity” and “CancerFinances: A Toolkit for Navigating Finances After Cancer.” This page also provides links to resources from other organizations as well as to research and data about financial toxicity. • OncoLink is a site that provides educational materials, including a variety of topics related to insurance, legal, employment, and financial concerns for oncology patients. • CancerCare has a searchable database to assist patients with finding local and national financial resources, along with some limited financial assistance. • Patients can access free professional support via CancerCare’s Hopeline (1-800 813 HOPE [4673]). Oncology social workers are available to assist patients in locating resources. • The Cancer Support Community’s Cancer Support Helpline (1-888-793-9355) offers a live web chat, licensed counselors, and financial navigators. • Some diagnosis-specific organizations also have financial resources available, for example, the Leukemia & Lymphoma Society and Living Beyond Breast Cancer. • Information and the required form for a Cancer Treatment Deferment Request is available from the Federal Student Aid website. Given that this is not your area of expertise, I’d suggest telling your patients to call their loan servicer directly with questions. For health care professionals who want to learn more, available resources include the Association of Community Cancer Centers’ (ACCC) Financial Advocacy Bootcamp and Triage Cancer’s Insurance and Finance Intensive. In recent years, more research has been published about the financial toxicity of a cancer diagnosis. Familiarize yourself with available data and then consider speaking with your oncology leadership team about the need for someone to be available within your team to address these concerns. There are more resources than can be included in this response; the ones mentioned will at least get your patient headed in the right direction for finding the assistance he or she is seeking. — Eucharia Borden, MSW, LCSW, OSW-C ■

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

8 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2020 • www.OncologyNurseAdvisor.com

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FEATURE | COVID-19 Pandemic

The Coronavirus SARS-CoV-2: 10 Myths About COVID-19 Misinformation can spread as quickly as disease; therefore, we offer clear explanations of commonly held misconceptions regarding this disease. Isolate from the first US case of COVID-19, seen on a transmission electron micrograph.

NATASHA PRIYA DYAL, MD

In our efforts to present timely information from reliable sources, the editors present this article from our sister publication Infectious Disease Advisor. The SARSCoV-2 pandemic is a rapidly evolving challenge for all healthcare providers, and misinformation is spreading as quickly as the virus. For example, the first myth presented here became fact in the short time between initial publication online and print production. Even we are scrambling to help you keep up. — The Editors

s infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to increase, there has been a concurrent increase in news and data, both accurate and inaccurate. Therefore, we have undertaken a review of a considerable amount of this information, and attempted to clarify some of the most recurrent misconceptions. For example, “coronavirus” is not the appropriate identifier for the cause of the current infection causing epidemics in >40 countries. Coronavirus is the name of a family of viruses, which cause infections in humans and animals.1,2 The current outbreak is caused by a strain of coronavirus that has been named SARS-Cov-2; the constellation of respiratory symptoms caused by this virus is called Coronavirus Disease 2019 (COVID-19).3 1. COVID-19 IS A PANDEMIC.

Although the World Health Organization (WHO) has avoided deeming the virus a pandemic, WHO director-general Tedros Adhanom Ghebreyesus said, “This virus has pandemic potential. This is 10 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2020 • www.OncologyNurseAdvisor.com

not a time for fear. This is a time for taking action to prevent infection and save lives now.”4 A pandemic is described as an epidemic that has progressed to a global scale. The term epidemic is applied for the case of an infection that spreads more rapidly than expected, over a large geographic area.5 Though the World Health Organization has classified COVID-19 as a pandemic as of March 11, 2020, this is unlikely to significantly affect the day-to-day lives of the general public. The new classification status, is just that: a classification. However, it does allow for an increased likelihood of resources to be allocated to controlling the infection by various government and public health organizations. 2. YOU CAN GET COVID-19 FROM PRODUCTS SHIPPED FROM CHINA.

The United States Centers for Disease Control and Prevention has not found any evidence to suggest that animals or animal products imported from China pose a risk for spreading COVID-19 in the United States.6 While it may be possible that a person can get COVID-19 by touching a surface or object that has the viral particles on it and then touching their own mouth, nose, or eyes, there has been no evidence to support this as the main way the virus spreads. In fact, one study reported that while the virus may live on surfaces for up to 9 days, “data on the transmissibility of coronaviruses from contaminated surfaces to hands were not found. However, it could be shown with influenza A virus that a contact of 5 [seconds] can transfer 31.6% of the viral load to the hands.”7 3. ANY COUGH-BASED ILLNESS IS COVID-19.

It is important to remember that in the United States, it is still flu season, and although it may be wrapping up, it can last through May.8 Further, there are several families of viruses that cause respiratory symptoms; these viruses (eg, rhinoviruses, adenoviruses, respiratory syncytial virus, human parainfluenza viruses) are the cause of the common cold, and circulate year-round.9,10 When is a cough concerning? If you feel sick with cough, fever, and difficulty breathing, and have been in close contact with a person known to have COVID-19, or if you live in or have recently traveled from an area with ongoing spread of COVID-19.6 4. COMMUNITY SPREAD MEANS ANYONE, ANYWHERE CAN GET THE INFECTION AT ANY TIME.

The term community spread is used to describe a situation wherein the exact source of an infection cannot be identified.11 This

commonly occurs in the setting of an epidemic: once the cases of an infection reach a certain point, a person may become infected without typical risk factors such as travel to an endemic area, or a person has close contact with a sick person. In this situation, one may not know when or where they encountered an infected individual. This person may also not yet know they are ill, as they may still be in an incubation or asymptomatic stage of the illness. However, contact is still a requisite for transmission, knowingly or unknowingly. Community spread of infections can be ameliorated through the practice of hand hygiene, and staying home when you feel unwell.6,12 5. EVERYONE WHO GETS INFECTED WITH SARSCOV-2 WILL DIE, OR CONVERSELY, ONLY ELDERLY, SICK PEOPLE WILL DIE.

Although the majority of cases that result in death are among the elderly, and individuals with chronic health conditions, COVID-19 has affected mostly all age groups, as well as people with no underlying diseases. There have been no deaths reported among children aged <9 years, who represent only 1% of all cases of infection.13 Individuals aged 10 to 19 years demonstrate a similar incidence, and those aged 20 to 29 years account for roughly 8% of cases.14 People aged 30 to 79 years, however, account for 87% of cases.13

It is important to remember that in the United States, it is still flu season; although it may be wrapping up, it can last through May. The fatality rate for COVID-19 is also skewed toward the elderly: people aged 70 to 79 years have a fatality rate of 8%, compared with 14.8% among those aged >80 years.13 People with any underlying comorbidity have a higher fatality rate.14 In addition, reports indicate more people of the male sex have been infected; they have also more often presented with more severe infection, and have had higher death rates.14 6. COVID-19 IS MORE TRANSMISSIBLE/DEADLIER THAN THE FLU.

This is tricky. Such statements can seem true if one is only looking at certain pieces of data, but data needs context. For example, the case fatality rate is frequently reported as being higher than that of the flu; however, it has already been demonstrated that fatality rates vary substantially across

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FEATURE | COVID-19 Pandemic These data demonstrate that this infection is more transmissible than the flu; preventive measures, however, are the same. patient populations. Moreover, comparing a rate of one infection to another when the factors that influence that rate (number of individuals infected and number of fatalities) are so significantly different is cumbersome. Seasonal influenza has a fatality rate of <1%,15 compared with the roughly 2% fatality rate currently reported for SARS-CoV-2. However, any subgroup analyses (eg, individuals who have died) of the roughly 35 million annual cases of the flu will, more often than not, mathematically find a smaller number compared with an analysis of the roughly 114,000 cases of COVID-19.16 However, current data on the transmissibility of SARSCoV-2 are more reliable in that calculations definitively take into account more variables.17 These data demonstrate that this infection is more transmissible than the flu; preventive measures, however, are the same. For this reason, all major health organizations, government officials, and even mass transit systems stress the importance of washing your hands frequently, coughing/sneezing into the crook of your elbow, and staying home when ill.6,12 7. FACIAL MASKS WILL KEEP YOU FROM GETTING SICK.

The use of facial masks as a preventive measure for COVID19 is not presently recommended for the general public.18 Healthcare workers who have direct contact with known cases of SARS-CoV-2 are recommended to use an N95 respirator mask, in conjunction with appropriate gowning and gloving techniques, and only in the hospital/clinic setting.18,19 The N95 filtering facepiece respirator functions by removing particles from the air as the individual breathes through the mask.19 Unlike these, other facemasks are only effective at preventing one from inhaling large respiratory droplets. The use of a non-N95 facemask is effective in preventing a person who is feeling unwell, or has a cough/ sneeze-based illness, from spreading an ongoing infection.

recommend cancelling travel to such places. Due to the circulation and air filtration system on airplanes, the risk for infection transmission is low; the CDC does, however, recommend conscientious hand hygiene in this case. Cruise ships put large numbers of people, potentially from a number of countries around the world, in frequent and close contact with each other; therefore the CDC strongly recommends frequent hand washing and avoidance of touching your face, and staying in your cabin and notifying the onboard medical center immediately if you feel unwell. 9. FLU OR PNEUMONIA VACCINES WILL ALSO HELP PREVENT COVID.

There are insufficient data to support the advocacy of the influenza or pneumococcal vaccines to prevent COVID19.21 While these 2 illnesses have similar symptomology to COVID-19, the vaccines are formulated to be active specifically against the influenza virus and streptococcal bacteria, neither of which contribute to COVID-19. However, it is highly recommended that everyone who is indicated to receive either vaccine does so because it may aid in simplifying the evaluation of potential SARS-CoV-2 infections.21,22 10. HEAT WILL KILL THE VIRUS.

Although a few high-ranking government officials have alluded to the possibility that high temperatures will kill the virus, there is not presently enough evidence to state this with scientific certainty. While the rate of most viral infections decreases during the summer months as a result of higher temperatures and humidity, there are 2 important caveats: people are less likely to be in close quarters with each other for lengthy periods; and although countries in the northern hemisphere are entering warmer months, the opposite is true for countries in the southern hemisphere.23 Further, previous experience with and research on the other Coronavirus epidemics (SARS and MERS) demonstrated that this family of viruses may have little problem surviving in warmer climates.23 ■ REFERENCES 1. Peiris JSM. Coronaviruses. In: Greenwood D, Barer M, Slack R, Irving W, eds. Medical Microbiology: A Guide to Microbial Infections. 18th ed. Elsevier; 2012:587-593.

8.YOU SHOULD NOT TRAVEL INTERNATIONALLY, AT ALL.

The CDC issues travel recommendations for several infectious diseases, including COVID-19.20 A Warning Level 3 indicates avoidance of all nonessential travel to a given location. An Alert Level 2 advises that people with chronic medical conditions and older adults should avoid travel to such locations. Watch Level 1 means that the CDC does not

2. Fehr AR, Perlman S. Coronaviruses: an overview of their replication and pathogenesis. Methods Mol Biol. 2015;1282:1-23. 3. The World Health Organization. Naming the coronavirus disease (COVID-19) and the virus that causes it. Updated February 11, 2020. Accessed March 23, 2020. https://www.who.int/emergencies/diseases/ novel-coronavirus-2019/events-as-they-happen References continue on page 15

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FEATURE | COVID-19 Pandemic

Do Patients With Cancer Need Specific Preventive Measures? These experts suggest the precautions being recommended for the general population are sufficient for patients with cancer — at least for now.

A nurse in the isolation ward of a hospital in western Germany demonstrates a test kit for coronavirus samples.

JOHN SCHIESZER

oronavirus disease 2019 (COVID-19) is a disease caused by SARS-CoV-2, a novel coronavirus fi rst detected in Wuhan City, Hubei Province, China.1 COVID-19 has the United States and many other countries coping with a major public health emergency. The US Centers for Disease Control and Prevention (CDC) is advising all healthcare providers to be suspicious if people who recently traveled internationally present with fever and respiratory symptoms. It also recommends that healthcare providers protect themselves by diligently following recommended infection control procedures. COVID-19 has caused illness and death, and its sustained person-to-person spread is concerning, especially for patients undergoing treatment for cancer. In general, patients with cancer are likely to be at higher risk of severe disease than patients who do not have cancer. Additionally, the more extensive the cancer and the more immunosuppressive their treatment, the more likely they are to experience complications, Peter Axelrod, MD, chair of infection control committees at Temple University Hospital and Fox Chase Cancer Center, Philadelphia, Pennsylvania, explained [email communication, February 27, 2020]. “There will likely be more detailed studies of [COVID-19] infection in cancer patients,” he added. Currently, a lot is still unknown about this disease and how it is spreading. In addition, there has not been any specific information regarding patients with cancer and COVID-19. However,

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FEATURE | COVID-19 Pandemic one study suggested a small percentage of patients had preexisting conditions including diabetes (6.4%), hypertension (12.8%), cardiovascular disease (3.7%), liver diseases (2.7%), malignancy (1.4%), and others (3.7%).2 A univariate analysis showed that comorbidity, age older than 50, lymphocyte counts <1500/μL, and serum ferritin >400 ng/mL at presentation were predictive of progression to severe disease. In this study, 73% of patients (11/15) with 3 or all 4 risk factors progressed to severe disease that required intubation or intensive care unit (ICU) admission compared with 11.8% (4/34) of patients with 0 to 2 risk factors (odds ratio [OR] 6.2; 95% CI, 1.7 to 22.8; P =.006).3 “None of the [patients] with absence of all 4 risk factors progressed to more severe diseases,” Dr Axelrod said. “But the low lymphocytes and high ferritin might just reflect the severity of the infection, not the underlying health of the patient.” Another study showed that patients were more likely to die from COVID-19 if they were older (OR 26.0) and had any comorbidity (OR 4.7), hypertension (OR 3.5), cardiovascular

Patients with leukemia and stem cell recipients are at greater risk of developing severe disease because their immune systems are impaired. disease (OR 5.1), endocrine system disease (OR 3.5), or respiratory system disease (OR 18.1). These patients exhibited shortness of breath (OR 11.8), confusion (OR 3.3), chest pain (OR 29.1), and fever plus cough plus shortness of breath (OR 4.4).4 If COVID-19 becomes more widespread, Dr Axelrod warned, patients should be advised to avoid crowded areas as much as possible and avoid having visitors or visiting people with respiratory infection symptoms. “If the number of cases becomes large, facemasks when going out in public may be helpful. The best ones are very close fitting, such as N-95 respirators, but they may be hard to find and breathing with them is often uncomfortable, especially for people with breathing issues,” he said. CANCER-SPECIFIC RISKS The patients with cancer with the highest risk of contracting the disease may be bone marrow transplant recipients; patients with chronic lymphocytic leukemia (CLL), non-Hodgkin lymphoma (NHL), and acute lymphoblastic leukemia (ALL); and those who are older than 65 and who have comorbid illnesses, John Green MD, section chief, Division of Infectious Diseases and Tropical Medicine and senior member of the Internal Medicine Department at Moffitt Cancer Center,

Tampa, Florida explained in an email [February 28, 2020]. “The highest risk patients are those who have immunodeficiency from defective T lymphocytes,” said Dr Green. Amanda F. Cashen, MD, from the Washington University School of Medicine Division of Oncology, Section of Stem Cell Transplantation, St Louis, Missouri, agreed that patients with leukemia and stem cell transplant recipients are at greater risk of developing severe disease because their immune systems are impaired [email communication, March 1, 2020]. “Many other respiratory viruses, including influenza and RSV, are common threats to my patients, and I always advise them to avoid contact with people who are sick, stay out of crowds, and use hand sanitizer,” explained Dr Cashen. If COVID-19 becomes more prevalent in the United States, these precautions will become more critical. “I would then advise my patients to stay at home as much as possible and to wear a mask when going out. I don’t think that guidelines specific to cancer patients are necessary,” she added. “Cancer patients can follow guidelines issued for all patients who are at increased risk of severe disease from [coronavirus].” Unless an otherwise healthy patient with cancer is on immunosuppressive therapy as part of their cancer treatment, Anthony V. D’Amico, MD, PhD, chief of the Division of Genitourinary Radiation Oncology at Dana Farber Cancer Institute, Boston, Massachusetts, said, there is no reason to believe they would be more susceptible to the coronavirus compared with any other virus [email communication, March 1, 2020]. “Standard precautions do exist for patients on immunosuppressive therapy for cancer. In addition, other reasons for immunosuppression, such as stress, poor health habits, autoimmune disorders, should be considered when counseling a patient regarding precautions,” noted Dr D’Amico. TAKING ACTION The International Health Regulations Emergency Committee of the World Health Organization declared the coronavirus outbreak a public health emergency of international concern in January 2020. Global efforts are focused concurrently on containing spread of the virus and mitigating its impact. Guidelines developed in anticipation of an influenza pandemic are being repurposed and adapted for a COVID-19 pandemic. The CDC has taken steps to enhance the response in the United States, establishing a COVID-19 Incident Management System and activating its Emergency Operations Center. A public health emergency was declared by US Health and Human Services Secretary Alex M. Azar II.1 But should oncology organizations develop their own guidelines specific to patients with cancer? David J. Prelutsky, MD, from the Washington University School of Medicine and the

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“I think following CDC guidelines is enough,” said Dr Prelutsky. “Most important is to let the physicians with public health expertise run the show.” medical director and founder of Southampton Healthcare, both in St. Louis, Missouri, does not believe this is necessary [email communication, DJ Prelutsky, March 1, 2020]. People with all the risk factors should be especially vigilant and follow a few basic guidelines, he noted. “I am telling my patients to practice good hygiene, such as handwashing, not touching mouth or

10 Myths

eyes without washing hands. Cover their own coughs and sneezes. I am also recommending avoiding crowds, if possible. Patients should get a flu shot, if they have not already. “I think following CDC guidelines is enough. No reason for all the societies, such as the American Society of Clinical Oncology (ASCO), to weigh in,” Dr Prelutsky said. “Most important is to let the physicians with public health expertise run the show.” ■ John Schieszer is a medical reporter based in Seattle, Washington. To read the complete article, including references, please see the online version at https://bit.ly/onacovid19precautions

13. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China [published

Continued from page 12

online February 24, 2020]. JAMA. doi:10.1001/jama.2020.2648 4. Nebehay S, Shields M. “Fatal mistake” for countries to assume they won’t get coronavirus -WHO chief. Reuters. Published February 27, 2020. Accessed March 23, 2020. https://www.reuters.com/article/us-healthchina-who/fatal-mistake-for-countries-to-assume-they-wont-get-coro-

14. Guan W, Ni Z, Hu Y, et al. Clinical chartacteristics of coronavirus disease 2019 in China [published online February 28, 2020]. N Engl J Med. doi:10.1056/NEJMoa2002032 15. Centers for Disease Control and Prevention. Disease burden of influenza. Updated January 10, 2020. Accessed March 23, 2020. https://www.cdc.

navirus-who-chief-idUSKCN20L236 5. Grennan D. What is a pandemic? [published online March 5, 2019]. JAMA.

gov/flu/about/burden/index.html 16. Johns Hopkins. Coronavirus COVID-19 global cases. Updated March 23,

doi:10.1001/jama.2019.0700 6. Centers for Disease Control and Prevention. How COVID-19 spreads. Updated March 4, 2020. Accessed March 23, 2020. https://www.cdc.gov/ coronavirus/2019-ncov/prepare/transmission.html 7. Kampf G, Todt D, Pfaender S, Steinmann E. Persistance of coronaviruses on inanimate surfaces and their inactivation with biocidal agents [published online February 6, 2020]. J Hosp Infect. doi:10.1016/j.jhin.2020.01.022 8. Centers for Disease Control and Prevention. The flu season. Updated July 12, 2018. Accessed March 23, 2020. https://www.cdc.gov/flu/about/

2020. Accessed March 23, 2020. https://gisanddata.maps.arcgis.com/ apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 17. Swerdlow DL, Finelli L. Preparation for possible sustained transmission of 2019 Novel Coronavirus: lessons from previous epidemics [published online February 11, 2020]. JAMA. doi:10.1001/jama.2020.1960 18. The World Health Organization. Coronavirus disease (COVID-19) advice for the public: when and how to use masks. Updated March 6, 2020. Accessed March 23, 2020. https://www.who.int/emergencies/diseases/ novel-coronavirus-2019/advice-for-public

season/flu-season.htm 9. Wein H. Understanding a common cold virus. National Institutes of

19. Centers for Disease Control and Prevention. Frequently asked questions

Health; April 13, 2019. Accessed March 23, 2020. https://www.nih.gov/

about personal protective equiptment. Updated February 29, 2020.

news-events/nih-research-matters/understanding-common-cold-virus

Accessed March 23, 2020. https://www.cdc.gov/coronavirus/2019-ncov/

10. Centers for Disease Control and Prevention. Common colds: protect yourself and others. Updated February 11, 2019. Accessed March 23, 2020. https://www.cdc.gov/features/rhinoviruses/index.html 11. Centers for Disease Control and Prevention. CDC confirms possible instance of community spread of COVID-19 in U.S. Updated February 26, 2020. Accessed March 23, 2020. https://www.cdc.gov/media/

questions and answers. Updated March 3, 2020. Accessed March 23, 2020. https://www.cdc.gov/coronavirus/2019-ncov/travelers/faqs.html 21. Yale Medicine. COVID-19 (Coronavirus Disease 2019). Accessed March 23, 2020. https://www.yalemedicine.org/conditions/covid-19/ 22. University of Chicago Medicine. COVID-19: what we know so far about

releases/2020/s0226-Covid-19-spread.html 12. Canadian Centre for Occupational Health and Safety. Good hygiene practices-reducing the spread of infections and viruses. Updated March 1, 2018. Accessed March 23, 2020. https://www.ccohs.ca/oshanswers/ diseases/good_hygiene.html

hcp/respirator-use-faq.html 20. Centers for Disease Control and Prevention. Travel: frequently asked

the 2019 novel coronavirus. Published on February 13, 2020. Accessed March 23, 2020. https://www.uchicagomedicine.org/forefront/ prevention-and-screening-articles/wuhan-coronavirus 23. Le Page M. Will heat kill the coronavirus?. New Scientist. 2020;245(3270):6-7.

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JOURNAL REVIEW

he nutritional status and body composition of patients with advanced cancer entering clinical trials may need greater attention. A new study has found that a significant number of patients involved in clinical trials may be malnourished and sedentary, possibly leading to inaccurate trial results. Researchers found that those patients who were malnourished had higher rates of adverse effects from therapy, higher rates of hospitalizations, lower response rates, and a shortened survival. Lead study author Rishi Jain, MD, assistant professor in the Department of Hematology/Oncology at Fox Chase Cancer Center, Philadelphia, Pennsylvania, said although worse outcomes are expected among patients with malnutrition, the magnitude of this effect was alarming. “There was [an approximately] twofold increased risk of hospitalizations and severe side effects in those who were malnourished. Also, patients who were malnourished were only able to stay on the clinical trial study for half as long,” explained Dr Jain. THE STUDY Previous research has shown that malnutrition and physical inactivity are common among patients with advanced cancer and are also associated with poor outcomes. Dr Jain and colleagues examined the relationships between baseline nutrition and exercise status with trial endpoints that included toxicity and survival. The researchers recruited 100 patients between July

Malnutrition, Inactivity May Be Hindering Trial Results John Schieszer

2016 and May 2017 and conducted baseline assessments of nutrition and exercise status prior to initiation of phase 1 and 2 oncology clinical trials. Among the 100 patients (54% female, 46% male), 60 were beginning trials studying immunotherapeutic agents and 87 were entering phase 1 trials. The median age was 60 (range: 28-85 years) and the median follow-up was 306 days. In this cohort, 55% had 0 to 2 prior lines of therapy and 71% had an Eastern Cooperative Oncology Group (ECOG) performance status of 1. Using Fisher’s exact test and chi-square analysis, the researchers examined whether demographics and baseline clinical measures were associated with critical malnutrition. They used Kaplan-Meier curves with log-rank tests to compare duration on study and overall survival (OS). WHAT WAS LEARNED The researchers found that 39% of patients enrolled in a phase 1 or 2

clinical trial were severely malnourished at the time of study initiation. The study showed that 52% of patients were sedentary, with minimal physical activity. “Patients who were malnourished at the time of study initiation had increased rates of side effects from therapy, hospitalizations, lower response rates, and a shortened survival,” Dr Jain reported. “We were very surprised by the magnitude of the effect baseline malnutrition had on outcomes.” Given how important phase 1 and 2 clinical trials are to identifying future cancer therapies, Dr Jain noted that there is an urgent need to understand the specific reasons why malnutrition may interfere with the effectiveness of these novel treatments, including immunotherapies. His team is now conducting research to better understand how dietary habits change during cancer treatment. Ultimately, the researchers are hoping to identify new avenues of treatment for preventing malnutrition in patients with advanced cancer. They also are exploring enhanced screening efforts to identify malnutrition early and intervene aggressively. Dr Jain and colleagues write that even though there is increasing awareness of the interactions between malnutrition, sarcopenia, and treatment-related outcomes and response, these factors are not commonly incorporated into therapeutic decision-making at the time of clinical trial consideration. They theorize that nutritional status Continues on page 18

Patients see their providers regularly while in clinical trials; however, nutritional issues may be deprioritized by concerns such as treatment-related adverse effects or therapy effectiveness. 16 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2020 • www.OncologyNurseAdvisor.com

RADIATION & YOUR PATIENT

RadiotherapyAssociated OM or Trismus in Head and Neck Cancer Bryant Furlow

ead and neck cancers and their treatment can cause painful and functionally significant acute and long-term oropharyngeal impairments, including oral mucositis (OM) and impaired tongue function, swallowing, and jaw opening (trismus, or “lock jaw”).1,2 Acute radiation mucositis involves scarring of the mucosal lining of the mouth, throat, and gastrointestinal tract. Radiation-induced trismus (RIT) is a late effect of treatment that results from scarring and contraction of jaw muscles, resulting in a limited ability to open the mouth; onset typically occurs between

9 and 12 months after radiotherapy is completed and over time, both musculature and mandibular joints degenerate.2 Unfortunately, researchers have yet to identify a definitive preventive strategy or cure for either condition. Treatment remains largely palliative, centering on pain management and avoiding malnutrition. Oral mucositis is common in patients undergoing systemic chemotherapy, affecting up to 40% of patients, and is ubiquitous in patients undergoing head and neck external-beam radiotherapy.3 OM involves progressive and increasingly painful damage to the oral cavity, pharyngeal, nasopharyngeal, laryngeal, salivary gland, and/or hypopharyngeal tissues.1 Worsening mucosal inf lammation and ulceration often begin to appear after the first 10 Gy (1 to 2 weeks, depending on fractionation schedule) of external-beam radiotherapy.1 Tongue, palate, and gum ulcerations can proliferate and merge by the time a cumulative radiation dose of 30 Gy has been delivered to oropharyngeal target volumes (typically, week 3 of radiotherapy).1 Both OM and RIT represent management challenges and appear to be related to one another; acute OM severity is believed to be associated with the risk of RIT.2 Both RIT and OM are progressive and can degrade nutritional status and quality of life. OM is a dose-limiting toxicity of both chemotherapy and radiotherapy and can lead to dose reductions and treatment interruptions, which in turn can affect treatment efficacy.1 Symptoms include pain, dehydration, anorexia and weight loss, dysphagia, and infection risk.1 Patients with RIT experience difficulty eating, drinking, speaking, and maintaining oral hygiene, which can lead to malnutrition and social isolation.2 In contrast to RIT, which is a late adverse event for many patients undergoing head

and neck radiotherapy, OM can sometimes begin to heal up to 4 weeks after radiotherapy is completed.1 Because of the treatment challenges of OM and RIT, much research effort has focused on identifying effective strategies for preventing these conditions and the palliative management of symptoms (eg, morphine-based analgesia).1,3 Not surprisingly, the most effective prevention strategy for OM involves minimizing the nontarget, healthy oral tissues that are included in high-dose radiation fields.1 Oral hygiene may also be important.1,3 The Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO) have promulgated clinical guidelines for preventing and managing OM that suggested flossing and tooth brushing with soft-bristled toothbrushes, and mouth rinsing with saline or sodium bicarbonate washes.1,3 In clinical practice, patients are usually advised to undergo dental corrections ahead of radiotherapy and to observe vigilant oral hygiene practices.1 No agent has yet been approved by the FDA for preventing OM in patients with head and neck cancers. The only FDA-approved preventive agent for OM in other cancers is the human recombinant keratinocyte growth factor palifermin (produced by E coli bacteria), which stimulates mucosal cell growth and has been approved for patients with hematologic cancers who undergo total body irradiation for autologous stem cell transplantation.1 Agents that have undergone clinical study but for which the evidence was insufficient to recommend their use in preventing or treating OM include antibacterial lozenges and mouth rinses, misoprostol, and granulocyte-colony stimulation factor.1 Continues on page 18

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RADIATION & YOUR PATIENT

Researchers have yet to identify a preventive strategy for either condition. Several phase 3 clinical trials are under way in the United States, France, and China, including studies of dusquetide (ClinicalTrials.gov Identifier: NCT03237325), ulinastatin (ClinicalTrials.gov Identifier: NCT03387774), and GC4419 (Clinical Trials.gov Identifier: NCT03689712).1 Dusquetide is believed to reduce inflammatory pathway signaling. In a phase 2 clinical trial, patients with locally advanced head and neck cancer undergoing concurrent cisplatin chemoradiotherapy saw a 50% reduction in duration of severe OM following dusquetide administration, compared to patients who were

Journal Review Continued from page 16

and physical performance may be key biomarkers of mechanisms mediating treatment-related toxicity. IMPLICATIONS FOR NURSES The researchers contend that the failure to address nutritional status and physical performance may come with a high price tag. They hypothesize it could lead to inaccurate dosing, excessive toxicity, increased health care costs from excessive hospitalizations, and compromised estimates of therapeutic efficacy. “While our study was purely observational in nature, it does add to the growing literature showing that compromised nutritional status and physical performance negatively affect cancer care and outcomes,” said Dr Jain.

administered placebo.1,4 In preclinical animal studies, low-level laser therapy (LLLT) has exhibited anti-inflammatory and wound healing effects and in human patients, pretreating patients with LLLT before concurrent chemoradiation with cisplatin was associated with reduced OM severity.1 However, LLLT’s safety has not been demonstrated and its effects on cancer cells has not been assessed.1 Although chewing gum, jaw exercises, and passive range of motion devices are widely used treatment strategies for RIT, the evidence base for these interventions remains equivocal. A recent study assessing 2 exercise interventions intended to reduce mouth opening among radiotherapy patients with head and neck cancers failed to demonstrate any benefit.2 In fact, exercise regimens might backfire; the study authors cautioned that exercises intended to reduce RIT severity could actually worsen patients’ pain.2 ■

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

Future studies should evaluate the impact of nutritional support in patients undergoing clinical trial therapy. Currently, Dr Jain and colleagues are looking into the relationship between nutritional status and other related measures such as changes in taste, muscle loss, and quality of life (QOL). “For now, our findings emphasize the importance of a thorough nutritional assessment in patients being considered for clinical trials and early nutritional intervention and physical rehabilitation when malnutrition is identified.” Patients see their providers (physician or advanced practice provider) regularly while in clinical trials; however, these visits are generally short and nutritional issues may be deprioritized by concerns such as treatment-related adverse effects or therapy effectiveness. For this very reason oncology nurses

have a pivotal role. “Patients who are undergoing clinical trials often spend many hours in clinical research units under nursing supervision. During this time, nurses may have an opportunity to explore nutritional concerns that exist at baseline or arise during therapy and ensure that these needs are being addressed and that referral to nutritional support services are provided,” Dr Jain explained. ■

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REFERENCES 1. Blakaj A, Bonomi M, Gamez ME, Blakaj DM. Oral mucositis in head and neck cancer: evidence-based management and review of clinical trial data. Oral Oncol. 2019;95:29-34. 2. Bragante KC, Groisman S, Carboni C, et al. Efficacy of exercise therapy during radiotherapy to prevent reduction in mouth opening in patients with head and neck cancer: a randomized controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol. 2020;129:27-38. 3. Lalla R, Bowen J, Barasch A, et al. MASCC/ ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014;120:1453-1461. 4. Kudrimoti M, Curtis A, Azawi S, et al. Dusquetide: a novel innate defense regulator demonstrating a significant and consistent reduction in the duration of oral mucositis in preclinical data and a randomized, placebo-controlled phase 2a clinical study. J Biotechnol. 2016;239;115-125.

John Schieszer is a medical reporter based in Seattle, Washington. REFERENCE Jain R, Handorf E, Khare V, Blau M, Chertock Y, Hall MJ. Impact of baseline nutrition and exercise status on toxicity and outcomes in phase I and II oncology clinical trial participants [published online November 20, 2019]. Oncologist. doi:10.1634/theoncologist.2019-0289

COMMUNICATION CHALLENGES

You Can if You Think You Can

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

The best way for anyone to hear the truth isn’t by listening to what I have to say, but by hearing themselves say it.

ust Do It” — Nike “Try not. Do … or do not. There is no try.” — Yoda, The Empire Strikes Back “You must do the things you think you cannot do.” — Eleanor Roosevelt ”When you have exhausted all possibilities, remember this: You haven’t.” — Thomas Edison “Never give up. Never give in.” — Ihadcancer.com The aquatic center where I swim for exercise has an Olympic length pool. Aspiring swimmers from club teams, high school, and junior Olympics all train there. So not surprisingly the large electronic activity board has a revolving display of inspirational quotes. The latest one is the title of this piece, “You can if you think you can.” When I read it, I immediately thought of a patient with stage IV lung cancer. CASE A nonsmoker, 55-year-old Jane came into the emergency department (ED) less than 2

months earlier with shortness of breath. She thought her cough was the lingering effect of a bad cold until she started to struggle to breathe. She told the doctor in the ED she was sure her cold had morphed into pneumonia. She had planned to see her own doctor the next day until her symptoms abruptly worsened. It was late on a Sunday when she realized she could not wait until the morning. One of the first things she said to me was that the ED doctor was even more surprised than she and her husband were when tests revealed a mass in her right lung that nearly blocked it entirely. Further tests showed the mass was not just in her lungs, but had spread to her bones and liver. She didn’t know it at the time, but she was dying before she ever had a chance to start treatment. But start she did. Unfortunately, even though she’d had 2 rounds of chemo, she became short of breath and was hospitalized. That was when I met her. In the course of the time between diagnosis and her return to the hospital, barely 2 months, her cancer had spread widely. Her right lung was essentially nonfunctional and her belly was filled with fluid. She could not lie flat because she could not breathe in that position. She felt terrible. Her difficulty breathing made her anxious. The stretch from carcinomatosis in her belly combined with the metastases to her ribs and pelvis kept her in pain. Our team walked into the room to meet her and she said, without any prompting, “I don’t want to be on any machines.” She was unable to string more than 5 or 6 words together before she experienced SOB, yet she managed to convey her wishes in a crystal clear fashion. The gravity of her situation was difficult to accept when she did not otherwise appear

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COMMUNICATION CHALLENGES

Our challenge was to help separate the fighter from the fight. It is a challenge we face with many of our patients.

to be sick. She hadn’t been ill long enough to have lost significant weight and become cachexic. Her hair was a lustrous gray, enviable in color and still thick. It was knotted in a braid down one shoulder. Her husband shook his head when she said she did not want to be connected to machines. “You can’t give up, darling. You can do it; I know you can.” I watched her smile at him, and it was clear that she saw and accepted his struggle. She reached over and patted his hand. DISCUSSION Inspirational sayings are just that: they are meant to inspire. The words are designed as a roadmap, a sideline cheer, a push when strength is flagging. There are no inspirational sayings for accepting reality. No one is going to say out loud, “Hey, it’s okay, cancer is tough. It is okay to let it beat you.” Often attempts at pointing out the reality of the situation are interpreted that way. Healthcare workers worry about taking away hope as much as our patients and families do. Yet without intending to, these sayings place a burden on patients. They communicate to them that failure is something they can control, that to beat cancer they must fight harder, not give up, never quit. A conversation with the family and friends of our patients is a challenge when they begin every conversation with a proclamation: She is a fighter. It is like throwing down a barricade. No one needs to talk about what-ifs or having a plan B because Mom is a fighter. In other words, leave us alone. When I am in a situation like I was with Jane, where I am presented with unrealistic expectations, I have to stop myself from telling people what to do. I have to hold my tongue sometimes, which isn’t easy. The best way for anyone to hear the truth isn’t by listening to what I have to say, but by hearing themselves say it. Our challenge is to nudge them toward that. But how? Reflective questioning is a strong place to start. “It sounds like Jane has been fighting for a long time,” I said, and then had to zip my lips

and wait for her husband to respond. After a moment he said, “She has been fighting this cancer for a long time, but she is a fighter.” I allowed for the space between us to expand before I said, “She must be exhausted.” Another long pause and he said, “Yes.” Then, rather than focusing on her being a fighter and the implicit connection to not giving up, I focused on how tiring her cancer and treatments were. How hard she was trying to get well. How much she wanted to keep fighting. How exhausting and disappointing it was. He nodded as I spoke. It was not an “ah-ha” moment for him. A light did not go on over his head. But he was able to embrace the realization that while she was still fighting she was running out of energy for the fight. When I cannot get a family member to shift away from the narrative of fighting, in spite of my best efforts, then I may resort to a metaphor. There are 2 I like to use. One is the prize fighter. All of the best prize fighters eventually lost. These people were literally trained to fight. Yet, at the end of their careers, they were not able to mount that level of fight. The second metaphor is about the natural aging process. My mother is 91. She cannot do what she could do even 10 years ago. She has not given up. But her body is not able to function as it once did. Both metaphors focus away from the person and onto what they are fighting. Being a “fighter” is about the character of the person, not the cancer. Jane’s husband struggled throughout her hospitalization. Her illness had progressed so rapidly he could not keep up. Hearing a distinction being made between his view of his wife as a fighter and the overwhelming battle she was in eased his suffering. It allowed him to see that she could be a fighter all the way down to her core and still not succeed in beating her cancer. Our challenge with him was to help separate the fighter from the fight. And it is a challenge we face with many of our patients. ■ Ann Brady is a symptom management care coordinator at a cancer center in Pasadena, California.

20 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2020 • www.OncologyNurseAdvisor.com

Individualized Pelvic Floor Muscle Training Improves Post Prostatectomy Outcomes Bette Weinstein Kaplan

s with many surgical procedures for malignancies, prostatectomy may resolve prostate cancer but it brings with it a number of postoperative sequelae, such as stress urinary incontinence (SUI) and pain. Interestingly, although the possibility of sexual dysfunction may loom large among many potential patients, incontinence is one of the most feared complications of a prostatectomy, according to the authors of a recently published review.1 This fear is not unfounded; 5% to 20% of patients will experience some degree of incontinence for up to 2 years after their prostatectomy, although it decreases as time goes on.1 Doctors have treated prostatectomyrelated incontinence with methods that begin with educating patients to make simple lifestyle adjustments. They may move on to pelvic floor muscle training (PFMT) that might include biofeedback. However, if those modalities prove ineffective, oral medications, extracorporeal magnetic innervation, external pelvic compression devices, injectable bulking agents, and surgical implantation of a male sling or artificial sphincter are other therapies that may resolve the patient’s incontinence. MUSCLE FUNCTION AND INCONTINENCE TYPE

Pelvic f loor dysfunction (PFD) manifests in 3 types: underactivity or

weakness; overactivity, which is tightness or muscle spasm often with muscle shortening; and dyssynergia, abnormal coordination with inappropriate or poorly timed movement. Pelvic f loor muscle training is a type of physical therapy that works to normalize pelvic muscle function. Prostatectomy causes a loss of urethral closing pressure, and pelvic floor muscle training teaches the patient how to use Kegel exercises for strengthening to counteract that. This technique is most effective at improving weakness. The authors note that pelvic rehabilitation practitioners now aim to avoid the one-size-fits-all approach that would

Current practice is to first normalize each patient’s pelvic floor dysfunction. apply to patients with almost any diagnosis, which was popular in the past. Current practice is to first normalize each patient’s pelvic floor dysfunction and then work on improving their incontinence and reducing postoperative pain. All the authors of this study are affiliated with University of Texas (UT) Southwestern Medical Center in Dallas,

Texas. Their premise was that Kegel exercises alone may not work for some postprostatectomy patients with stress urinary incontinence. For example, if the type of PFD is overactivity, not underactivity or weakness, the muscle is tight; exercises would make it even tighter but not stronger. RESOLVING INCONTINENCE AND PAIN

This retrospective review was conducted to determine how well patients responded to individual types of PFMT. For the study, the researchers reviewed the charts of 136 patients who had undergone robotic-assisted prostatectomy performed by the same urologic surgeon. All the patients had developed urinary incontinence and were referred to the physical therapy department between 2009 and 2014. Reduced incontinence The patients were referred to physical therapists who specialized in evaluating and treating pelvic floor dysfunction. They determined that only 25 of the patients had underactive or weak pelvic floor muscles, whereas 13 had overactive or tight muscles. Of note, 98 patients were determined to have had mixed-type PFD. Their pelvic floor muscles were both weak and tight, components of underactivity and overactivity, respectively. All patients received individual Continues on page 23

www.OncologyNurseAdvisor.com • MARCH/APRIL 2020 • ONCOLOGY NURSE ADVISOR 21

Helping Patients Manage Treatment-Related Changes to Senses of Taste, Smell Bette Weinstein Kaplan

ancer patients frequently experience dietary difficulties with foods they associate with their disease or its treatment. These patients may suffer from reduced appetite and low food intake, resulting in unintentional weight loss. A number of factors contribute to this, according to sensory scientist Alissa Nolden, PhD, assistant professor of food science at the University of Massachusetts (UMass) Amherst. Alterations in smell and taste perception are often implicated when patients suffer from lack of appetite. Researchers at UMass Amherst conducted a review and analysis of studies in the literature on changes in taste and smell experienced by cancer patients while undergoing treatment and afterward to determine the prevalence of these changes in this population. Included studies directly measured the psychophysical response of cancer patients to taste and/ or olfactory stimuli and assessed the food behavior of people affected by cancer including their preferences, enjoyment, and dietary intake.1 Although the UMass Amherst team restricted selected studies to those involving adults older than 18, the studies included all types of cancer and treatment. Their search produced 11 studies published between 1982 and 2018, and comprising 578 participants (380 with cancer and 198 who served as controls). Five studies included patients

with more than one type of cancer; patients in the remaining 6 studies had just one type of cancer. The cancer types represented in the studies included breast, colon, esophagogastric, lung, ovarian, prostate, and testicular cancers; lymphoma; and multiple myeloma. A variety of objective measures were used to gauge smell and taste perception, including detection threshold (the lowest concentration at which a taste stimulus is detected compared with a background such as water) and recognition threshold (the lowest concentration at which a specific taste, such as bitter, is recognized). Taste stimuli were administered to the whole mouth as a rinse or to part of the mouth with a taste strip. Smell studies used pen-like devices that dispensed odors. Food behavior was evaluated for those studies that included measures of dietary intake by recall, food frequency questionnaires, food weights, or responses to food pictures. TREATMENT-RELATED CHANGES Taste Almost all the studies had mea-

sured participants’ changes in taste for sweet, sour, bitter, and salty. Most results demonstrated changes in taste of sweet and that the cancer patients who had a loss of appetite usually preferred food that was less sweet compared with those who had a normal appetite. Other studies showed that changes in taste of bitter were associated with the patients

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avoiding meat, chocolate, and tea. Some patients had difficulty recognizing sweet and bitter tastes. Longitudinal studies demonstrated a significant relationship between taste and food behavior. For example, one study described a patient who began having difficulty identifying the taste solutions during the third chemotherapy treatment cycle and consequently consumed less food. In another study, patients became more sensitive to sweet after 2 cycles of chemotherapy and consumed less protein than those who were not sensitive to sweet; and in a third case, a patient had decreased sensitivity to sweet and a reduced appetite before undergoing any treatment. Smell No significant changes were evident in the studies that measured changes in olfactory function. Although many people with cancer report differences in how they perceive smells, no studies showed an association between taste, food behavior, and smell function. “Taste and smell are separate sensory systems and do not appear to be associated. This means that a poor or reduced sense of taste does not mean that the individual will also experience a reduced sense of smell. But each of these systems contributes to our overall sensation of flavor,” Dr Nolden explained (oral communication, January 2020). The type of cancer treatment appears to strongly correlate with the prevalence

of taste problems, she noted. Even with different chemotherapy regimens, the type of therapeutic agent, number of cycles, and other variables can impact incidence and severity of taste changes. Other pathologies such as a history of alcohol abuse, smoking, and surgery in the oral cavity would also impact the taste system, perhaps irreversibly. Nurses can help by talking to the patient prior to treatment to prepare them for this experience. There are no clinically proven strategies, but there are many recommendations available as no one strategy works for all patients. Dr Nolden suggested trying several different things until something helps with managing taste loss, which usually involves modifying the diet. PERSPECTIVES FROM A HOSPITAL CHEF

Chef Pnina Peled offered some tips for helping patients and survivors deal with taste and appetite issues (oral communication, January 29, 2020). Formerly the executive chef at Memorial Sloan Kettering Cancer Center, Chef Peled is currently senior executive chef at New York-Presbyterian Hospital, both in New York, New York, and

Total Patient Continued from page 21

physical therapy for their type of PFD, and 87% experienced significant improvement in their incontinence. Reduced pain Pelvic pain was also a problem experienced by 27% of the patients, most often manifesting in those patients with mixed-type PFD. Pelvic physical therapy reduced that to 14%. The authors explained that patients with a component of overactivity have

Type of treatment appears to correlate with prevalence of taste problems. has in-depth understanding of what works for these patients. “From my experience, patients come in to the hospital eating the things that they like and then after treatment they often don’t want them anymore. So I alter the food to make it palatable because there are certain things [patients] are not able to taste any longer. It’s important to focus on what they can taste: things that are salty, spicy, lemony, or vinegary,” explained Chef Peled. “Those are flavors that stay with their taste buds, so to speak. So if you add [those flavors], they get some kind of taste from their food, rather than it having no taste to them at all. “In my experience patients have aversions to certain smells, so I wouldn’t serve them a plate covered with a lid. I serve children foods in kid-friendly, cute, takeout containers rather than on plates with lids. For the adults, I just

shortened pelvic muscles and develop trigger points, leaving them unable to contract strongly enough to prevent incontinence. Individualized physical therapy increases muscle length by relaxing the pelvic floor, enabling stronger and more functional contractions and reducing pain. The UT Southwestern group report theirs is the first study to demonstrate that pelvic physical therapy can lead to decreased pain for a statistically significant portion of men who experience

wouldn’t use a lid. Use plastic wrap to keep it fresh. Then unwrap it before going into the room, letting the smell dissipate outside [the room] rather than taking the lid off in front of the patient. That sudden smell often triggers a strong feeling of nausea,” Chef Peled explained. “If a patient tells you, ‘I can’t stand that.’ Answer, ‘Okay, you don’t have to have that.’ Then add whatever flavors you need to get the food to taste like what the patient is used to.” Chef Peled noted that doing so often involves adding strong flavors such as spice, lemon, salt, or vinegar. “[The food] may be too intense and inedible to someone with a normal palate, but to the cancer patient, those flavors taste mild and make the food more tolerable.” Patients going through treatment are lucky if they even want to eat anything, so Chef Peled advocates giving them what they want. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE Nolden AA, Hwang LD, Boltong A, Reed DR. Chemosensory changes from cancer treatment and their effects on patients’ food behavior: a scoping review. Nutrients. 2019;11(10):2285.

pain after prostatectomy, and call for more research on helping postprostatectomy patients. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE Scott KM, Gosai E, Bradley MH, et al. Individualized pelvic physical therapy for the treatment of postprostatectomy stress urinary incontinence and pelvic pain [published online December 5, 2019]. Int Urol Nephrol. doi:10.1007/s11255-019-02343-7.

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ASK A PHARMACIST

Adverse Effects of Antiemetic Prophylaxis; Improving Iron Absorption Some of my patients on 5-HT3 antagonists (eg, ondansetron [Zofran], granisetron [Kytril], palonosetron [Aloxi], others) complain that the side effects prevent them from taking these medications as prescribed. How should these be managed so patients can take their antiemetic prophylaxis?

Two of the most common adverse effects of the 5-HT3 antagonists include constipation and headaches. Constipation may occur with all agents in this class, including ones administered through a nonoral route (ie, parenteral or topical). It occurs more frequently with higher doses of these agents. Management should consist of proactive strategies, including adequate water and fiber intake, and considering use of stool softeners or stimulant laxatives as needed. Headaches may be managed using acetaminophen or NSAIDs (eg, ibuprofen [Motrin, Advil], naproxen [Aleve]) as appropriate. Switching between 5-HT3 antagonists is typically effective to prevent future headaches. What are some ways to improve oral iron absorption for patients with iron-deficiency anemia? — Name withheld upon request

A variety of oral iron supplements are available over-the-counter (OTC). Iron

is best absorbed on an empty stomach (ie, take 2 hours before or 4 hours after a meal); however, if patients experience GI upset, it may be taken with a small amount of food. Avoidance of dairy products, calcium supplements, fiber supplements, coffee, and tea are important as these reduce iron absorption from the GI tract. Some medications, such as antacids and certain antibiotics (eg, tetracycline or fluoroquinolone antibiotics such as levofloxacin [Levaquin]) can reduce absorption, as well. Iron absorption is enhanced by vitamin C, thus taking these supplements with some orange juice (or a vitamin C supplement) can also improve absorption. Some data suggest that taking oral iron every other day can improve absorption; this strategy is best in patients receiving a limited course of iron supplementation rather than those taking it indefinitely. Oral iron supplements can cause constipation; increasing water and fiber intake can help to mitigate this. In patients who are unable to achieve adequate iron stores despite optimal supplementation, parenteral iron products may be necessary. ■

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

— Name withheld on request

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! 24 ONCOLOGY NURSE ADVISOR • MARCH/APRIL 2020 • www.OncologyNurseAdvisor.com