Oncology Nurse Advisor May/June 2014 by Haymarket Media

ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014

www.OncologyNurseAdvisor.com

May/June 2014

A F O R U M F O R P H YS I C I A N A S S I S TA N T S

ONCOLOGIC SURGERY

FEATURE

Survey offers insight on coping with advanced prostate cancer

THE TOTAL PATIENT

Healing Arts Program: A collaboration for patients and nurses

C101: EMPOWER YOUR PATIENT

The power of the e-patient

Evidence-based nursing guidelines for surgical management of sarcoma Hemipelvectomy, classified as a type I,II,III pelvic resection, is the established therapeutic procedure for primary bone and soft tissue sarcoma.

THE PATIENT’S VOICE

Nurses’ choices

TYPE

Iliac

RADIATION & YOUR PATIENT

Breaking the silence on treatmentrelated sexual dysfunction

COMMUNICATION CHALLENGES

Peter Rabbit & Mrs. McGregor’s pie VOLUME 5, NUMBER 3

FROM CANCERCARE

Cancer and the workplace

MAJOR PELVIC RESECTIONS

TYPE

Periacetabulum

TYPE

III

Pubis

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Subscriptions: www.OncologyNurseAdvisor.com/freesub Reprints: Wright’s Reprints (877) 652-5295 Permissions: www.copyright.com Oncology Nurse Advisor is the official publication of the National Coalition of Oncology Nurse Navigators. Oncology Nurse Advisor (ISSN 2154-350X), May/June 2014, Volume 5, Number 3. P ublished 6 times annually by Haymarket Media Inc, 114 West 26th Street, 4th Floor, New York, NY 10001. Oncology Nurse Advisor is available on a paid subscription basis at the following annual rates: USA $75, Canada $85, all other Foreign $110; Single copy price: USA $20; Foreign $30. To order, visit our Web site at www. OncologyNurseAdvisor.com or 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.

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

Jia Conway, DNP, FNP-BC, AOCNP, NP-C Cancer Care Associates of York York, Pennsylvania

Michele M. Farrington, BSN, RN, CPHON University of Iowa Hospitals and Clinics Iowa City, Iowa

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

Arati Jairam-Thodla, MSN, CNP Northwestern Memorial Prentice Women’s Hospital Chicago, Illinois

Karen MacDonald, RN, BSN, CPON William Beaumont Hospital Royal Oak, Michigan

Marlene McGuire, RN, MA, ANP-C The Cancer Institute of New Jersey New Brunswick, New Jersey

Maribel Pereiras, PharmD, BCPS, BCOP Hackensack University Medical Center Hackensack, New Jersey

Leah A. Scaramuzzo, MSN, RN-BC, AOCN Billings Clinic, Inpatient Cancer Care Billings, Montana

Lisa A. Thompson, PharmD, BCOP Kaiser Permanente Colorado

Rosemarie A. Tucci, RN, MSN, AOCN Lankenau Hospital Wynnewood, Pennsylvania

www.OncologyNurseAdvisor.com • MAY/JUNE 2014 • ONCOLOGY NURSE ADVISOR 5

CONTENTS

May/June 2014

IN THE NEWS • XBP1 gene key to TNBC progression • Wisconsin is 38th state to adopt an ‘apology’ law • Navigator Notes: The role of the navigator and its effect on health care reform • Suppression of a single protein can shut down pancreatic cancer

ONCOLOGY NURSE ADVISOR FORUM • Advocating for treatment of anticipatory reactions • Impact of drug substitution on overall cancer survival • Pain management in patients with low BP • Nail care tips for patients undergoing chemotherapy • Protocols for concomitant infusions in the same IV line

FEATURES Hemipelvectomy: Providing evidence-based nursing care Rachel Chandy, RN, BSN, CMSRN; Silvestina DeCoteau, RN, MSN, NEA, BC

50 FIND US ON

Survey offers insight on coping with advanced prostate cancer Jeffrey Albaugh, PhD, APRN, CUCNS

STAT CONSULT Obinutuzumab (Gazyva)

RADIATION & YOUR PATIENT Breaking the silence on treatment-related sexual dysfunction Bryant Furlow

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JOIN OUR COMMUNITY Submit a question to an oncology nurse advisor Have a question? Our panel of oncology clinicians is available to answer your questions. Submit questions to editor.ona@HaymarketMedia.com.

C101: EMPOWER YOUR PATIENT Trends in cancer care: The power of the e-patient Sarah Krüg

COMMUNICATION CHALLENGES Peter Rabbit & Mrs. McGregor’s pie Ann J. Brady, MSN, RN-BC

ISSUES IN CANCER SURVIVORSHIP How men used humor to cope with the devastating physical consequences of penile cancer Bette Weinstein Kaplan

Answer the ONA poll question ONA asks… Answer our poll question and compare your opinions with those of your colleagues on key nursing issues at OncologyNurseAdvisor.com Subscribe to ONA newsletters Stay current with daily news reports and special series from key oncology conferences on our Web site, sign up for our e-newsletters at OncologyNurseAdvisor.com/subscribe. Earn CE credits

THE TOTAL PATIENT The Healing Arts Program at Montefiore: A collaboration that heals patients and nurses Bette Weinstein Kaplan

FROM CANCERCARE How to manage cancer and the workplace Anna L. Eckhardt, LCSW

Each issue offers one new CE activity co-provided by the Nurse Practitioner Healthcare Foundation. Activities are active for 2 years. Socialize electronically Keep up with the oncology field through our social media. We’re on Twitter and Facebook. Now, we’re on Pinterest, too. Follow us!

THE PATIENT’S VOICE Nurses’ choices Denise Menonna Quinn, RN-BC, MSN, AONS

ASK A PHARMACIST Imatinib and radiotherapy; management of terminal agitation Lisa A. Thompson, PharmD, BCOP

www.OncologyNurseAdvisor.com • MAY/JUNE 2014 • ONCOLOGY NURSE ADVISOR 7

IN THE NEWS A GENE not previously associated with breast cancer appears to play a pivotal role in the growth and progression of triple-negative breast cancer (TNBC). These results suggest that targeting the gene may offer a new approach to treating the disease. In triple-negative breast cancer, tumor cells do not express the genes for human epidermal growth factor receptor 2 (HER2), the estrogen receptor, or for the progesterone receptor. Approximately 42,000 new cases of TNBC are diagnosed in the United States each year. This is approximately 20% of all breast cancer diagnoses. Triple-negative breast cancer is a very aggressive malignancy and few treatment options are available. The disease usually recurs 1 to 3 years after treatment. Investigators studied several types of cell lines derived from breast cancers and found that the gene XBP1 was especially active in triple-negative breast cancer cells. The gene XBP1 played a critical role in the development of TNBC, causing cells to become malignant and enhancing disease recurrence after treatment. When XBP1 activity was suppressed in laboratory cell cultures and animal models, the size of tumors was reduced along

with the likelihood of disease recurrence. This effect was amplified when gene suppression was used in conjunction with the chemotherapy drugs doxorubicin or paclitaxel. The findings suggest that XBP1 controls the transformation of normal breast cells into malignant cells. Suppression of XBP1 expression combined with chemotherapy could be an effective treatment for triple-negative breast cancer. “Patients with the triple-negative form of breast cancer are those who most desperately need new approaches to treat their disease,” said Laurie H. Glimcher, MD, dean and professor of medicine at Weill Cornell Medical College in New York, New York. “This

Cross-section showing the mechanism of action of trastuzumab on a cancerous breast cell overexpressing HER2 receptors.

Suppression of XBP1 expression combined with chemotherapy could be an effective treatment for triple-negative breast cancer. 10 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014 • www.OncologyNurseAdvisor.com

biochemical pathway was activated in about two-thirds of patients with this type of breast cancer. Now that we understand how this gene helps tumors proliferate and return after a patient’s initial treatment, we can develop more effective therapies to shrink the tumors’ growth and delay recurrence.” Another regulator of transcription, HIF1-alpha, is very active in triple-negative breast cancer cells. The scientists found that interactions between XBP1 and HIF1-alpha might be involved in malignant transformation of normal cells. “This shows how cancer cells co-opt the endoplasmic reticulum stress response pathway, allowing tumors to grow and survive when they are deprived of nutrients and oxygen,” said lead author Xi Chen, PhD, a postdoctoral associate at Weill Cornell. “The interaction between these two critical pathways enables the cells to deal with a hostile microenvironment. This offers new strategies to target TNBC.” “We need to know whether what we observed in the laboratory models occurs in patients,” said coauthor Jenny Chang, MD, professor of medicine at Weill Cornell Medical College and director of the Houston Methodist Cancer Center. “We are very excited about the prospect of moving forward as soon as possible for the benef it of patients.” This study was published in Nature (doi:10.1038/ nature13119). ■

XBP1 gene key to TNBC progression

Wisconsin is 38th state to adopt an ‘apology’ law APOLOGIES BY health care workers are protected from being used against them in court by a new law enacted in Wisconsin, which is one of more than 35 states to enact such a law. The law, Assembly Bill 120, was signed by Governor Scott Walker on April 8, 2014, in Madison. The intent of the law is to make statements of apology or condolence by health care providers inadmissible as evidence. The legislation could foster more conversations between health care providers and patients/family members when such interaction is needed most. The bill includes statements, gestures, and conduct that express “apology, benevolence, compassion, condolence, fault, liability, remorse, responsibility, or sympathy to a patient or his or her relative or representative.” These type of statements will not risk being admissible in civil action, administrative hearing, disciplinary proceedings, mediation, or arbitration as evidence of liability. Speaking for the Wisconsin Medical Society, Society President Richard A. Dart, MD, said, “AB120 will foster more patientphysician interactions exactly when they’re needed most.” ■ Go to the online version of this news story to read a Commentary on how these laws apply to nurses.

Navigator Notes: The role of the navigator and its effect on health care reform The cost of chronic illnesses in the United States has increased dramatically and the need to develop a cost-effective approach to improve the management of chronic disease among vulnerable populations is needed. Many of the health care reform initiatives have focused on the underserved and uninsured population through providing the right to health care, access, sustainability, and quality of care. Good health care is accessible, affordable, available, appropriate, and accountable. Patient navigation and the role of the nurse navigator are essential in facilitating good health care to the population they serve. Many patients have difficulty accessing health care and navigating the complex system. Many times there are disparities and/or barriers to care such as language, culture, education level, level of trust in the health care system, and psycho-social needs, in addition to being in an underserved population. Navigation is the process by which an assigned navigator assesses individual needs; plans for education, coordination, communication, and support; and implements effective transitions through the illness trajectory. In addition, the navigator should also evaluate the effect of the navigation process on the patient, family, and the organization’s outcomes. As with any model of care delivery the desired outcomes should be identified, measured, and evaluated. The navigation processes and services should reflect the strengths and desired results, as well as address the challenges of the community system and facility in which the navigation program resides.

The nurse navigator facilitates improved health care access and quality of care for the underserved/uninsured population, and bridges the gap through advocacy and care coordination. Currently, most navigators within cancer centers are professionals whose clinical nursing guides patients, families, and their caregivers to informed decision-making, collaborating with a multidisciplinary team to allow for timely cancer screening, diagnosis, treatment, and increased supportive care across the continuum. Navigators play an integral role in health care reform and cost containment. Their involvement in patient care can reduce hospital admissions and/ or re-admissions for the cancer patient. Additional areas of controlling health care cost are preventing delays in the diagnosis, staging, and treatment of the oncology patient in various oncology settings, and maintaining consistency in the care of the patient. When a patient is navigated around the barriers to care, their ability to accept and remain in care is improved, leading to better adherence, potentially less treatment, improved quality of life, more diligent follow-up, and earlier detection of recurrence or complications of disease or treatment, precious health care dollars. When resources are allocated appropriately and used effectively, complications are minimized and outcomes are improved. This extends far beyond the single patient. The cost savings through the use of patient navigation ensure more money is available to research disease causes, detection, treatment, and prevention. ■

www.OncologyNurseAdvisor.com • MAY/JUNE 2014 • ONCOLOGY NURSE ADVISOR 11

Take a bite out of G-CSF acquisition costs* GRANIX is another option in short-acting G-CSF therapy TM

» GRANIX demonstrated a 71% reduction in duration of severe neutropenia (DSN) vs placebo1 – GRANIX significantly reduced DSN when compared to placebo (1.1 days vs 3.8 days; p<0.001)1 – Efficacy was evaluated in a multinational, multicenter, randomized, controlled, Phase III study of chemotherapy-naïve patients with high-risk breast cancer receiving doxorubicin (60 mg/m2 IV bolus)/docetaxel (75 mg/m2)1 *Based on wholesale acquisition cost (WAC) of all short-acting G-CSF products as of November 11, 2013. WAC represents published catalogue or list prices and may not represent actual transactional prices. Please contact your supplier for actual prices.

» Safety was evaluated in 3 Phase III clinical trials1

Indication

Important Safety Information (continued)

» GRANIX (tbo-filgrastim) Injection is a leukocyte growth factor indicated for reduction

» Use in patients with sickle cell disease: Severe and sometimes fatal sickle cell crises can occur

in the duration of severe neutropenia in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia.

in patients with sickle cell disease receiving hG-CSFs. Consider the potential risks and benefits prior to the administration of GRANIX in patients with sickle cell disease. Discontinue GRANIX in patients undergoing a sickle cell crisis.

» Potential for tumor growth stimulatory effects on malignant cells: The granulocyte colony-

Important Safety Information » Splenic rupture: Splenic rupture, including fatal cases, can occur following the administration of human granulocyte colony-stimulating factors (hG-CSFs). Discontinue GRANIX and evaluate for an enlarged spleen or splenic rupture in patients who report upper abdominal or shoulder pain after receiving GRANIX.

» Acute respiratory distress syndrome (ARDS): ARDS can occur in patients receiving hG-CSFs. Evaluate patients who develop fever and lung infiltrates or respiratory distress after receiving GRANIX, for ARDS. Discontinue GRANIX in patients with ARDS.

» Allergic reactions: Serious allergic reactions, including anaphylaxis, can occur in patients receiving hG-CSFs. Reactions can occur on initial exposure. Permanently discontinue GRANIX in patients with serious allergic reactions. Do not administer GRANIX to patients with a history of serious allergic reactions to filgrastim or pegfilgrastim.

stimulating factor (G-CSF) receptor, through which GRANIX acts, has been found on tumor cell lines. The possibility that GRANIX acts as a growth factor for any tumor type, including myeloid malignancies and myelodysplasia, diseases for which GRANIX is not approved, cannot be excluded.

» Most common treatment-emergent adverse reaction: The most common treatment-emergent adverse reaction that occurred in patients treated with GRANIX at the recommended dose with an incidence of at least 1% or greater and two times more frequent than in the placebo group was bone pain. Please see brief summary of Full Prescribing Information on adjacent page. For more information, visit GRANIXhcp.com. Reference: 1. GRANIX TM (tbo-filgrastim) Injection Prescribing Information. North Wales, PA: Teva Pharmaceuticals; 2013.

Take a bite out of G-CSF acquisition costs* GRANIX is another option in short-acting G-CSF therapy TM

» Safety was evaluated in 3 Phase III clinical trials1

Indication

Important Safety Information (continued)

» GRANIX (tbo-filgrastim) Injection is a leukocyte growth factor indicated for reduction

» Use in patients with sickle cell disease: Severe and sometimes fatal sickle cell crises can occur

in the duration of severe neutropenia in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia.

» Potential for tumor growth stimulatory effects on malignant cells: The granulocyte colony-

BRIEF SUMMARY OF PRESCRIBING INFORMATION FOR GRANIX™ (tbo-filgrastim) Injection, for subcutaneous use SEE PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION 1 INDICATIONS AND USAGE GRANIX is indicated to reduce the duration of severe neutropenia in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. 4 CONTRAINDICATIONS None. 5 WARNINGS AND PRECAUTIONS 5.1 Splenic Rupture Splenic rupture, including fatal cases, can occur following administration of human granulocyte colony-stimulating factors. In patients who report upper abdominal or shoulder pain after receiving GRANIX, discontinue GRANIX and evaluate for an enlarged spleen or splenic rupture. 5.2 Acute Respiratory Distress Syndrome (ARDS) Acute respiratory distress syndrome (ARDS) can occur in patients receiving human granulocyte colony-stimulating factors. Evaluate patients who develop fever and lung infiltrates or respiratory distress after receiving GRANIX, for ARDS. Discontinue GRANIX in patients with ARDS. 5.3 Allergic Reactions Serious allergic reactions including anaphylaxis can occur in patients receiving human granulocyte colony-stimulating factors. Reactions can occur on initial exposure. The administration of antihistamines‚ steroids‚ bronchodilators‚ and/or epinephrine may reduce the severity of the reactions. Permanently discontinue GRANIX in patients with serious allergic reactions. Do not administer GRANIX to patients with a history of serious allergic reactions to filgrastim or pegfilgrastim. 5.4 Use in Patients with Sickle Cell Disease Severe and sometimes fatal sickle cell crises can occur in patients with sickle cell disease receiving human granulocyte colony-stimulating factors. Consider the potential risks and benefits prior to the administration of human granulocyte colony-stimulating factors in patients with sickle cell disease. Discontinue GRANIX in patients undergoing a sickle cell crisis. 5.5 Potential for Tumor Growth Stimulatory Effects on Malignant Cells The granulocyte colony-stimulating factor (G-CSF) receptor through which GRANIX acts has been found on tumor cell lines. The possibility that GRANIX acts as a growth factor for any tumor type, including myeloid malignancies and myelodysplasia, diseases for which GRANIX is not approved, cannot be excluded. 6 ADVERSE REACTIONS The following potential serious adverse reactions are discussed in greater detail in other sections of the labeling: • Splenic Rupture [see Warnings and Precautions (5.1)] • Acute Respiratory Distress Syndrome [see Warnings and Precautions (5.2)] • Serious Allergic Reactions [see Warnings and Precautions (5.3)] • Use in Patients with Sickle Cell Disease [see Warnings and Precautions (5.4)] • Potential for Tumor Growth Stimulatory Effects on Malignant Cells [see Warnings and Precautions (5.5)] The most common treatment-emergent adverse reaction that occurred at an incidence of at least 1% or greater in patients treated with GRANIX at the recommended dose and was numerically two times more frequent than in the placebo group was bone pain. 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. GRANIX clinical trials safety data are based upon the results of three randomized clinical trials in patients receiving myeloablative chemotherapy for breast cancer (N=348), lung cancer (N=240) and non-Hodgkin’s lymphoma (N=92). In the breast cancer study, 99% of patients were female, the median age was 50 years, and 86% of patients were Caucasian. In the lung cancer study, 80% of patients were male, the median age was 58 years, and 95% of patients were Caucasian. In the non-Hodgkin’s lymphoma study, 52% of patients were male, the median age was 55 years, and 88% of patients were Caucasian. In all three studies a placebo (Cycle 1 of the breast cancer study only) or a non-US-approved filgrastim product were used as controls. Both GRANIX and the non-US-approved filgrastim product were administered at 5 mcg/kg subcutaneously once daily beginning one day after chemotherapy for at least five days and continued to a maximum of 14 days or until an ANC of ≥10,000 x 106/L after nadir was reached.

Bone pain was the most frequent treatment-emergent adverse reaction that occurred in at least 1% or greater in patients treated with GRANIX at the recommended dose and was numerically two times more frequent than in the placebo group. The overall incidence of bone pain in Cycle 1 of treatment was 3.4% (3.4% GRANIX, 1.4% placebo, 7.5% non-US-approved filgrastim product). Leukocytosis In clinical studies, leukocytosis (WBC counts > 100,000 x 106/L) was observed in less than 1% patients with non-myeloid malignancies receiving GRANIX. No complications attributable to leukocytosis were reported in clinical studies. 6.2 Immunogenicity As with all therapeutic proteins, there is a potential for immunogenicity. The incidence of antibody development in patients receiving GRANIX has not been adequately determined. 7 DRUG INTERACTIONS No formal drug interaction studies between GRANIX and other drugs have been performed. Drugs which may potentiate the release of neutrophils‚ such as lithium‚ should be used with caution. Increased hematopoietic activity of the bone marrow in response to growth factor therapy has been associated with transient positive bone imaging changes. This should be considered when interpreting bone-imaging results. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category C There are no adequate and well-controlled studies of GRANIX in pregnant women. In an embryofetal developmental study, treatment of pregnant rabbits with tbo-filgrastim resulted in adverse embryofetal findings, including increased spontaneous abortion and fetal malformations at a maternally toxic dose. GRANIX should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In the embryofetal developmental study, pregnant rabbits were administered subcutaneous doses of tbo-filgrastim during the period of organogenesis at 1, 10 and 100 mcg/kg/day. Increased abortions were evident in rabbits treated with tbo-filgrastim at 100 mcg/kg/day. This dose was maternally toxic as demonstrated by reduced body weight. Other embryofetal findings at this dose level consisted of post-implantation loss‚ decrease in mean live litter size and fetal weight, and fetal malformations such as malformed hindlimbs and cleft palate. The dose of 100 mcg/kg/day corresponds to a systemic exposure (AUC0-24) of approximately 50-90 times the exposures observed in patients treated with the clinical tbo-filgrastim dose of 5 mcg/kg/day. 8.3 Nursing Mothers It is not known whether tbo-filgrastim is secreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when GRANIX is administered to a nursing woman. Other recombinant G-CSF products are poorly secreted in breast milk and G-CSF is not orally absorbed by neonates. 8.4 Pediatric Use The safety and effectiveness of GRANIX in pediatric patients have not been established. 8.5 Geriatric Use Among 677 cancer patients enrolled in clinical trials of GRANIX, a total of 111 patients were 65 years of age and older. No overall differences in safety or effectiveness were observed between patients age 65 and older and younger patients. 8.6 Renal Impairment The safety and efficacy of GRANIX have not been studied in patients with moderate or severe renal impairment. No dose adjustment is recommended for patients with mild renal impairment. 8.7 Hepatic Impairment The safety and efficacy of GRANIX have not been studied in patients with hepatic impairment. 10 OVERDOSAGE No case of overdose has been reported. ©2013 Cephalon, Inc., a wholly owned subsidiary of Teva Pharmaceutical Industries Ltd. All rights reserved. GRANIX is a trademark of Teva Pharmaceutical Industries Ltd. Manufactured by: Distributed by: Sicor Biotech UAB Teva Pharmaceuticals USA, Inc. Vilnius, Lithuania North Wales, PA 19454 U.S. License No. 1803 Product of Israel GRX-40189 January 2014 This brief summary is based on TBO-003 GRANIX full Prescribing Information.

IN THE NEWS

FDA Update The FDA approved ramucirumab (Cyramza) for the treatment of advanced stomach cancer or gastroesophageal junction adenocarcinoma. Ramucirumab is an angiogenesis inhibitor intended for patients whose cancer is unresectable or metastatic after treatment with a fluoropyrimidine- or platinum-containing therapy. Clinical trial results showed ramucirumab led to a median overall survival of 5.2 months compared with 3.8 months with a placebo. Results from a second clinical trial that evaluated the efficacy of ramucirumab plus paclitaxel versus paclitaxel alone also showed an improvement in overall survival. Common side effects experienced during clinical testing include diarrhea and high blood pressure. The FDA approved ofatumumab (Arzerra Injection, for IV infusion) in combination with chlorambucil for patients with previously untreated chronic lymphocytic leukemia (CLL), for whom fludarabinebased therapy is considered inappropriate. The recommended dose and schedule for this indication is 300 mg on day 1 followed 1 week later by 1,000 mg on day 8 (cycle 1) followed by 1,000 mg on day 1 of subsequent 28 day cycles for a minimum of 3 cycles until best response or a maximum of 12 cycles. ■

Suppression of a single protein can shut down pancreatic cancer INHIBITING A single protein completely shuts down the growth of pancreatic cancer, according to new research. Suppressing Yes-associated protein (Yes) stopped any further growth of pancreatic cancer, though it did not stop it first developing, according to the study’s data from animal models and human cancer cells. The study was conducted at the Georgetown Lombardi Comprehensive Cancer Center at Georgetown University in Washington, DC, and published in Science Signaling (2014; doi:10.1126/scisignal.2005049). “We believe this is the true Achilles heel of pancreatic cancer, because knocking out Yes crushes this really aggressive cancer,” said the study’s senior investigator, Chunling Yi, PhD, an assistant professor of oncology at Georgetown Lombardi. The study was conducted in mouse models of pancreatic ductal

“We believe this is the true Achilles heel of pancreatic cancer, because knocking out Yes crushes this really aggressive cancer.”

ONA ASKS …

adenocarcinoma (PDAC). These mice have a mutation in the KRAS gene, as well as a mutation in their p53 gene. “More than 95% of pancreatic cancer patients have a KRAS mutation and about 75% have a mutation in p53, so these mice provide a natural model of the human disease,” she said. Because devising drugs that target either KRAS or p53 has been very difficult, the researchers looked for other potential targets involved in uncontrolled growth of pancreatic cancer. They found that Yes was overexpressed in both mouse models and human samples of PDAC, and they discovered that the KRAS mutation found in most pancreatic cancer activates Yes. “The KRAS mutation uses Yes to make cancer cells grow, so shutting down Yes defuses the mutated gene’s activity,” Yi said. Yes also shuts down activity of the p53 oncogene; however, the link between p53 and Yes is not yet known. ■

YES

ASCO created new tools for managing obesity-related challenges. How comfortable are you discussing weight management with patients? Go online to answer our poll question. We’ll publish the results and a new question in the next issue. …AND YOU ANSWERED In the last issue we asked if you discuss practices such as yoga, cognitive behavioral therapies, or hypnosis with patients.

44.5% Yes, these practices can help 26.5% Only if the patient asks me about them 29% No, I don’t know enough about

these to provide information

www.OncologyNurseAdvisor.com • MAY/JUNE 2014 • ONCOLOGY NURSE ADVISOR 15

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

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

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

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

QUESTIONS & ANSWERS ADVOCATING FOR TREATMENT OF ANTICIPATORY REACTIONS What can nurses do to advocate for the use of medications such as lorazepam (Ativan) for anticipatory nausea when the physician is reluctant to prescribe antianxiety or sleep medications? —Marva Victor, RN, BSN, OCN An effective way to change behavior in clinicians is to provide evidence for best practices, such as National Cancer Institute (NCI) guidelines for managing the side effects of cancer and cancer treatment, including nausea and vomiting. These can be accessed through the NCI web site (www.cancer.gov). Anticipatory nausea and vomiting (ANV) is a conditioned response seen in 25% to 30% of patients typically in their third or fourth chemotherapy cycle, usually as a result of the patient experiencing acute or delayed nausea and vomiting in previous chemotherapy cycles. Benzodiazepines have no intrinsic antiemetic activity as a single agent, but are useful as adjuncts by providing anxiolytic and anterograde amnesic effects. Behavioral techniques such as systematic desensitization are also effective. However, the best approach to prevent ANV is to control nausea and vomiting in the first cycle of chemotherapy. —Kerstin Lappen, RN, MS, ACNS, ACHPN

IMPACT OF DRUG SUBSTITUTION ON OVERALL CANCER SURVIVAL How does chemotherapy agent substitution affect the overall survival rate of oncology patients? —Denise Baker, MSN, RNC-TNP, OCN Definitively, how agent substitution affects the overall survival rate of oncology patients is not quantifiable as of yet; however, what is understood about drug substitution is that it is a very risky process that can lead to the death of the patient. Unpredictable drug shortages lead to rationing of care and prioritizing treatment accordingly to accommodate those patients with the potential for cure or more favorable outcomes. The greatest compromise to overall survival is appreciated when there are no drug substitutions available for specific regimens, such as cytarabine for the treatment of acute myelogenous leukemia (AML). —Jiajoyce R. Conway, DNP, CRNP, FNP-C, AOCNP

PAIN MANAGEMENT IN PATIENTS WITH LOW BP I am constantly confronted with this situation in the acute care setting: Pain medication is often withheld when an oncology patient’s blood pressure is low. How is this situation best managed? —Jeri L. Ashley, MSN, RN, AOCNS, CHPN

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16 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014 • www.OncologyNurseAdvisor.com

Low blood pressure is not an absolute contraindication to administering pain medication. When in doubt, ask for parameters from the physician who prescribed the medication, then monitor, assess, and treat the patient’s pain. The key to answering this question is to understand there is no single correct answer. Each patient situation must be assessed individually. Considerations to weigh: Is the patient opioid tolerant? Does the decrease in BP correlate with a change in pain medication, or is it independent? What else may be causing the low blood pressure? Is the patient awake and alert, or sedated? Low blood pressure is not an absolute contraindication to administering pain medication. When in doubt, ask for parameters from the physician who prescribed the pain medication, then monitor, assess, and treat the patient’s pain. —Ann Brady, MSN, RN-BC

NAIL CARE TIPS FOR PATIENTS UNDERGOING CHEMOTHERAPY I have frequently heard patients with breast cancer complain of drainage, brittle nails, or nails falling off while undergoing chemotherapy. Are there any evidence-based practices for managing changes to nails during chemotherapy? —Mina Duca, RN, BSN, OCN Several evidence-based practices are reported to help prevent/relieve damage to nails caused by chemotherapy. • Wear rubber gloves when doing household chores such as washing dishes or using cleaning products to protect your hands. Also, wear gloves while doing any outside chores such as gardening. • Be cautious when getting a manicure or other cosmetic nail treatments. If you choose to get a manicure, bring your own nail care implements. Avoid having acrylic nails or wraps applied because bacteria can grow behind the synthetic nail or wrap and possibly cause an infection. • Nail polish is safe to wear unless a nail is cracked or falling off. Use a nonacetone remover to take off nail polish.

FREE!

• Monitor your cuticles. Hang nails may develop. Use cuticle cream to keep them moisturized. Do not cut, pull, or tear away dry cuticles or hang nails. —Rosemarie Tucci RN, MSN, AOCN

PROTOCOLS FOR CONCOMITANT INFUSIONS IN THE SAME IV LINE What is the protocol for using the same intravenous line for concomitant infusions of IV chemotherapy drugs with other IV medications? Our agency policy is that chemotherapy is infused alone as a secondary line (Y-ed in with sodium chloride primary line) and no other agents used through that line. I am unable to find guidelines in regard to why the same line cannot be used when compatible drugs are being infused. —Titza Suvalcu, RN, MSN, OCN Y-ports, also known as piggybacks, provide a second access point in intravenous tubing for additional IV medications, such as administering chemotherapeutic agents concurrently with supportive care fluids and/or medications. The most common setup is to have maintenance fluids, such as normal saline or lactated Ringer, infusing as the primary fluid. Chemotherapy is normally administered through a secondary port or Y-port. Many medications must be given on a pump and cannot be infused through a Y-port connection. One should become familiar with the institution’s procedures concerning proper administration for all IV fluids and chemotherapy medications. This subject is so exhaustive that a simple answer would not do it justice. A good reference article is “Chemotherapy Administration Sequence: A Review of the Literature and Creation of a Sequencing Chart” ( J Hematol Oncol Pharm. 2011;1(1):17-25). —Donald R. Fleming, MD

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FEATURE | Hemipelvectomy

Hemipelvectomy: Providing evidence-based nursing care Meeting the challenges of the significant morbidity, functional impairment, and alterations in body image in patients undergoing this surgical resection. RACHEL CHANDY, RN, BSN, CMSRN; SILVESTINA DECOTEAU, RN, MSN, NEA, BC

Combination resections are named by combining the respective numbers (eg, hemipelvectomy is designated type I,II,III)

H TYPE

Iliac

MAJOR PELVIC RESECTIONS

TYPE

Periacetabulum

TYPE

III

Pubis

emipelvectomy, a surgical procedure involving resection of either the pelvis or innominate bone, is an established therapeutic procedure for the management of primary bone and soft tissue sarcomas. This procedure is associated with significant morbidity, functional impairment, and alterations in quality of life and body image.1 A thorough pre- and postoperative nursing assessment of the hemipelvectomy candidate is essential to promoting enhanced physiologic and quality-of-life outcomes for these patients. In addition, proactive discharge planning can be critical to preparing patients and their family caregivers for transition to the outpatient setting. Hemipelvectomy is usually performed in highly specialized tertiary/ quaternary medical centers by a comprehensive surgical oncology team. Approximately 30 to 50 hemipelvectomy surgeries are completed annually at the University of Texas MD Anderson Cancer Center. SARCOMA Sarcomas are broadly defined as a heterogeneous group of rare and solid tumors that originate in the connective tissue or bone, including— but not limited to—muscle, fat, blood vessels, or supporting tissues of the body.2 Soft-tissue sarcomas are the most frequently diagnosed sarcomas in adults, with an estimated 12,020 cases in the United States in 2014. Fifty percent of these tumors arise in the mesodermal tissues

18 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014 • www.OncologyNurseAdvisor.com

of the extremities, 40% in the trunk and retroperitoneum, and 10% in the head or neck.3 The American Cancer Society estimates that 4,740 deaths will be attributed to soft-tissue sarcomas in 2014.3 Soft-tissue sarcomas are classified according to the originating soft tissue, with the grade reflecting the metastatic potential of the tumor.3 Staging of soft tissue sarcomas, which is determined by tumor size, histologic grade, and lymph node or distant site involvement, is essential to determining the most effective treatment.3 Multimodal treatment of soft tissue sarcoma is the most common approach and includes pre- and post-operative radiation in combination with surgical resection.3 Primary bone tumors are extremely rare in adults. In the United States, they account for fewer than 0.2% of all cancers and have an annual incidence of approximately 2,500 cases and an annual mortality of 1,400.2 Osteosarcomas are the most common primary bone tumors in the pelvis and account for 35% of cases.4 Osteosarcoma is diagnosed predominantly in adolescents and young adults and accounts for an estimated 450 new cases in the United States each year among persons age birth to 24 years.5 Osteosarcoma is classified as either central (medullary) or surface (peripheral). Its staging is determined by tumor grade and size and by the presence of discontinuous tumors in the primary bone site or distant metastases.5 Osteosarcoma is treated with systemic neoadjuvant (preoperative) or adjuvant (postoperative) chemotherapy along with complete resection of all clinically detectable disease.5 More than 80% of patients with extremity osteosarcoma can be treated with limb-sparing surgery. However, patients who undergo amputation have lower local-recurrence rates, although no difference in overall survival is observed among patients based on initial treatment with these two approaches.5 HEMIPELVECTOMY Pelvic resection is a commonly used surgical approach in the management of sarcomas. A limb-sparing surgical procedure is always preferable, but in cases in which partial pelvic resection does not allow for safe surgical margins or limb functionality, hemipelvectomy may be indicated.1 Specifically, patients presenting with metastatic primary bone tumors or patients for whom resection of at least two of the following—the sciatic nerve, the femoral neurovascular bundle, and the hip joint—require resection for adequate margins are potential candidates for hemipelvectomy.4 The incidence of hemipelvectomy in the United States is unknown but is estimated at approximately one case per

1 million annually.4 Hemipelvectomy is classified as either internal (a local resection of the hemipelvis that preserves the ipsilateral lower extremity) or external (involving resection of the innominate bone [ilium, pubis, and ischium] and the entire lower extremity).6 Hemipelvectomy procedures are traditionally defined by Enneking’s classification of pelvic lesion resection, which includes three types: • Resection confined to the ilium • Resection confined to the periacetabulum • Resection confined to the pubis Postoperative complications occur in 20% to 50% of cases and most commonly include wound infection and flap necrosis.4 Additional considerations include the challenges of postoperative prosthetics, including difficulty in anchoring the prosthetic, some of which require a waist and shoulder strap, as well as the energy expenditure related to the swing

Each team member should become involved prior to surgery because establishing a trusting relationship with the patient is critical. gait required to ambulate with the prosthetic. Both of these often preclude older patients from prosthetic use.4 Quality of life and functional status are also significant considerations for patients undergoing hemipelvectomy. Pain and fatigue are reported sequelae of patients who have had a hemipelvectomy2; however, several studies have shown impressive improvement or maintenance of functional status following this procedure.2,7 Although not directly measured in studies to date, clinical observations reveal the potential for an altered body image following this procedure.1 PREOPERATIVE ASSESSMENT AND NURSING CARE Preoperative assessment for hemipelvectomy is undertaken with a team approach that allows for assessing the patient and ensures caregivers’ understanding of the treatment plan and postoperative sequelae. The multidisciplinary team may include the surgeon, plastic surgeon, clinical nurse, physical therapist, nutritionist, chaplain, social worker, and case manager. Each member of the team should become involved in the care process prior to surgery because establishing a trusting relationship between the patient and the health care team is critical. It is important for the patient and caregiver

www.OncologyNurseAdvisor.com • MAY/JUNE 2014 • ONCOLOGY NURSE ADVISOR 19

FEATURE | Hemipelvectomy to be educated about the potential loss of bowel and bladder functions and other postoperative complications, such as impaired skin integrity, flap necrosis, loss of neurologic function, motor strength atrophy, and contractures. Bowel and bladder management are individualized, with the goals of protecting bladder function and preventing loss of anal tone. Individualized bowel and bladder training programs may be utilized to address these complications.7 Routine preoperative patient education should address physical therapy, counseling, prosthesis use, and rehabilitation program to promote mobility. Additional educational sessions should include deep breathing and coughing exercises and dietary restrictions prior to surgery. The preoperative preparations should begin with an appointment with the surgeons for an intensive discussion of the procedure and its outcomes as part of the informedconsent process. The hemipelvectomy work-up includes a complete blood count, metabolic panel, coagulation panel, blood typing, and cardiac enzymes. Because blood loss is expected, blood transfusion is a standard procedure during surgery and as needed postoperatively. Two days prior to surgery, the patient should be instructed to consume a clear liquid diet and to use a bowel-cleansing preparation to thoroughly cleanse the bowel in order to reduce the possibility of contaminating the wound from the anus. On the day of surgery, a nasogastric tube is placed to facilitate postoperative nutrition, and a Foley catheter is inserted to keep the bladder empty during surgery and to manage the anticipated paresis of the bladder postoperatively. POSTOPERATIVE ASSESSMENT AND NURSING CARE Postoperative nursing care is provided in the intensive care unit for 24 to 48 hours, during which time the patient’s cardiac function, kidney function, electrolytes, blood loss, and neurologic function are closely monitored. Intravenous antibiotics, anticoagulants, and electrolyte replacement may be initiated. When the patient’s condition is stable, he or she may be transferred to an orthopedic or specialty care unit where nursing care is provided until discharge. The use of specialty mattresses and routine repositioning may reduce the risk of skin breakdown and an overhead trapeze may be used to facilitate mobility. Given the risk of wound infection and flap necrosis, a detailed skin and surgical site assessment is integral to effective nursing care. Consultation with a pain-management team should be considered to properly manage postoperative pain and contribute to the patient’s comfort when engaging in physical therapy. Collaboration with physical and occupational therapists to engage the patient in early mobilization is critical to

postoperative recovery. Respiratory assessment is essential to identifying potential postoperative respiratory infection, and incentive spirometry should be encouraged to enhance respiratory function and reduce the risk of infection. NURSING CONSIDERATIONS Hemipelvectomy is a physically and potentially psychologically altering procedure. Nursing considerations must include detailed assessment as described above, coupled with attention to the educational, psycho-emotional and discharge planning needs of the patient and caregiver. Engaging a multidisciplinary approach to caring for this patient population is critical to postoperative recovery. The nurse and the patient’s family should encourage positive feedback and adaptive behaviors with the patient to enhance recovery. Balancing rest and nutrition needs is also important to the recovery process. Proper body alignment and active and passive range-of-motion exercises should be encouraged. Patients must be educated on the use of prosthesis and adaptive devices, such as a wheelchair or underarm crutches or cane. Partnering with physical therapists to build strength and prevent complications, such as back pain and scoliosis, is very important. Moreover, patients must continue their follow-up care at the outpatient clinic for any increased phantom pain, abnormal bone growth, skin abrasions related to prosthesis use, and routine blood work and tests to monitor for tumor recurrence. Given that sarcoma is most prevalent among adolescents and young adults, several concerns may be addressed with these and any age groups undergoing hemipelvectomy.

Engaging the familial caregiver in this process is one way of enhancing support for the patient pre- and postoperatively and into recovery. Discussions may include an open dialogue and education about sexual intimacy and psycho-emotional support as the patient navigates engaging socially, professionally, and personally. Providing information and discussing community resources and support groups can help the patient transition back to the community. Functional and emotional changes that occur during this stage necessitate a complex interdisciplinary approach to physical therapy; hence, including culturally and spiritually sensitive and attentive care is important.

20 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014 • www.OncologyNurseAdvisor.com

Rachel Chandy is a clinical nurse at the University of Texas MD Anderson Cancer Center in Houston, Texas. Silvestina DeCoteau is an associate director, also at the University of Texas MD Anderson Cancer Center.

ONS REFLECTI

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, DNP, CRN Jia Conway

st Patients mu y feel that the have their ce, voi own can y that the at decide wh they need.

ent. Her stop treatm sted wanted to because she and her body was exhau pract icchemother soul was tired, that I’ve been of different n the 10 years one thing I’ve come from the onslaught had developed be sia, And now she ing oncology, chemotherapy can apy regimens. ar-plantar erythrodysesthehair that apy is other own to learn a painful palm or a foe. Chem brush ing her was lost. either a friend place. It has its time which made even hope an, its wom quantity and difficult. For this certainly has romised that was so comp a patient both her ver, we quality of life s she cherished for when it gives As clinicians, howe come Her ing thing life. quality of there also may both even the little lf were becom t that herse of aware to do them are all too apy robs life er cancer patien t abilit y chemother Only anoth nal and leaves the patien a time when a challenge. d the perso quantity and s instead. bly understan outcomes quality and uncertain g side effect a can possi of r itatin ess with cance debil er unter ate darkn battling for intim ng cancer. Only anoth libert y a recent enco the d I remember undergoing treatment battli rstan in unde was s from t can possibly ienced in being able patient who t cancer. As I sat acros back patien she exper metastatic breasas she struggled to hold and power ent.” ing face anymore treatm want to give up her, watch to say “no ed down her never ible stream we oath the tears that gized for feeling so “horr t As clinicians, st cancer. We take an to patien our abilit y battle again way, she apolo always known this and when every our I had embraced medical facts, preserve life, and weak.” ling. to nged by the exam ine the who fiercely as a fighter now she was really strugg r the do this is challe and is step back in the absence I had to delive we can do treatment, but t preser ve life times when always ready for all very instan mean ing of Even in those this true cine. In this news, she was like presble medi her that horri cal seen ded most of physi I was remin the cost of . I had never had the this patient, the next round particular day, she not be at She with this life should nt’s wishes before. On world on her shoulders. ervat ion of ecting a patie ve . weight of the say No to everything en is life’s quality. Resp think we can achie l to nove , “Wh of what we just wanted ventions and not and she asked took her in spite inter me at cal d d medi d at her, She looke s we shoul er with new gh?” I looke agents mean to stop enough, enou “The decision about whethon chemotherapy nt’s desire ide a patie for us to offer hand, and said, apy is not based ip try to overr chemother so important can say how onsh cratic relati that treatment. It is to continue where they It’s a demo e they nts a place dictatorsh ip. have the right to decid must feel that even patie feel. Patients can decide treatment, in which you they truly , that they want any morenow.” own voice and not s their selve you do not for have them ion is just in a very long they need—for if that decis the first time he a sigh of what one else. I think for breat her for every she could time, she felt now that I didn’t judge relief. She knew

BORUT TRDINA

REFLECTIONS

LOGY 44 ONCO

NURSE ADVIS © ISTOCKPHOTO.COM /

CONCLUSION Hemipelvectomy is a rare but significant surgical intervention in the management of patients with aggressive sarcoma diagnoses. Nursing care of the patient must begin prior to surgery and address the numerous physiologic and psychosocial sequelae resulting from such an invasive procedure. Engaging the familial caregiver in this process is one way of enhancing support for the patient pre- and postoperatively and into recovery. It is important to ensure that nurses are well prepared to conduct physical and psycho-emotional assessments to address both postoperative complications, such as infection and flap necrosis, as well as immediate and long-term psycho-emotional sequelae, including alterations in body image. This is critical to managing the care of these patients and supporting the transition back to their home and community settings. Particular attention must be given to the developmental needs of adolescent and young adult patients because such surgery impacts their quality of life and social engagement with peers. Proper education and support from health care providers, family caregivers, and community resources can contribute to a successful transition to the community setting. ■

OR • JUNE

I had become so involved in the “big picture” of patient care that I had forgotten the importance of reviewing the smaller details.

Seeing the forest for the trees r.com urseAdviso

OncologyN

2010 • www.

Robin Wachsman, RN,

BSN, OCN, CCRN

have been privileged to serve as a medi- granddaughter was to be married and, with cal oncology nurse for the past 23 years. I his fatigue and shortness of breath, he always considered it a calling, knew and caring he would not be able to attend her wedding. for those with life-threaten ing illness- I resolved to find a resolution for es has been fulfi lling and Mr. E’s challenging. symptoms so he could make the trip. Oncology nurses are charged with constant changes in therapy. New oral chemotherapy SEARCHING medications and other therapeutics FOR A CAUSE lead to I evaluated any new challenges and new and all causes that could have patient successes had this profound effect on him. I every day. We have to be reviewed on our toes all all of his bloodwork including CBC, the time. I tell newly hired BMP, nurses, “This is and tumor markers. CBC revealed decreased a thinking nurse’s job!” hemoglobin and hematocrit, In practice, I focus on maintaining which met the quality indication for of care, enhancing clinical ESA therapy, and I hoped standards, and the growth supporting progressive research, factors would improve Mr. E’s but I had fatigue. To complete become so involved in the the search for answers, I “big picture” of ordered a PET scan to rule out metastasis. patient care that I had forgotten the imporAs the test tance of reviewing the smaller details. A unremarkab results came back, including an recent patient, Mr. E, caused le PET scan showing stable disme my big-picture focus and evolve to reassess ease, Mr. E’s symptoms remained relatively my approach unchanged. to more holistic patient care. Even with the ESA therapy, his hemoglobin levels did not Mr. E is a vibrant 90-year-old improve. Once man whose again, I dug infectious laughter can often in my heels and searched for be heard reso- answers. I reevaluated every step of nating throughout the his care chemo room. He from A to Z; despite this, Mr. is a special patient; that rare E was still person with a fatigued with shortness of breath. magnetic personality that Or, to put draws people to it in his words, “just plain tuckered his side. Nine months ago, out.” he was given a What was I missing? diagnosis of stage IV colorectal cancer. Mr. E’s performance status was excellent with few comorbitie s, so we s I reviewed all his test results proceeded with chemotherapy. After cycle with the nursing staff, one 3, however, Mr. of E was showing signs of my new trainees asked, “How severe fatigue and lethargy, and the hearty about his iron stores?” laughter that once The flowed through the room light went on! Mr. E’s iron with had diminished. As you might each visit studies were not current, and we had initiguess, he was ated ESA therapy. Could this be functional not a complainer, but in a quiet moment he iron deficiency anemia? Mr. E’s revealed his greatest concern iron stores to me. His great were adequate at the initiation of therapy,

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NURSE ADVISOR 43

REFERENCES 1. Mat Saad AZ, Halim AS, Faisham WI, et al. Soft tissue reconstruction following hemipelvectomy: eight-year experience and literature review. ScientificWorldJournal. 2012;2012:702904. doi:10.1100/2012/702904. 2. Granada-Cameron C, Hanlon AL, Lynch MP, Houldin A. Experience of newly diagnosed patients with sarcoma receiving chemotherapy. Onc Nurs Forum. 2011;38(2):160-169. 3. Adult Soft Tissue Sarcoma Treatment (PDQ). Bethesda, MD: National Cancer Institute. http://cancer.gov/cancertopics/pdq/treatment/adultsoft-tissue-sarcoma/HealthProfessional. Updated February 28, 2014. Accessed May 19, 2014. 4. Mayerson JL, Wooldridge AN, Schaschmidt TJ. Pelvic resection: current concepts. J Am Acad Orthop Surg. 2014;22(4):214-222. doi:10.5435/JAAOS-22-04-214. 5. Osteosarcoma and Malignant Fibrous Histiocytoma of Bone Treatment (PDQ). Bethesda, MD: National Cancer Institute. http://cancer.gov/ cancertopics/pdq/treatment/osteosarcoma/HealthProfessional. Updated May 2, 2014. Accessed May 19, 2014. 6. Lackman RD, Crawford EA, Hosalkar HS, et al. Internal hemipelvectomy for pelvic sarcomas using a T-incision surgical approach. Clin Orthop Relat Res. 2009;467(10):2677-2684.

Do you have a story about a patient you want to share? Oncology Nurse Advisor welcomes narrative essays from oncology nurses for Reflections, our narrative medicine department. Write 1,200 words about an experience with a patient that was especially meaningful to you, and email the manuscript to editor.ona@haymarketmedia.com.

7. Beck LA, Einerston MJ, Winemiller MH, et al. Functional outcomes and quality of life after tumor-related hemipelvectomy. Phys Ther. 2008;88(8):916-927. doi:10.2522/ptj.20070184.

www.OncologyNurseAdvisor.com • MAY/JUNE 2014 • ONCOLOGY NURSE ADVISOR 21

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FEATURE | Coping with prostate cancer

Survey offers insight on coping with advanced prostate cancer Ninety-one men and 100 caregivers shared their thoughts on what worries them most when advanced prostate cancer becomes a way of life. JEFFREY ALBAUGH, PhD, APRN, CUCNS

rostate cancer is the most commonly diagnosed cancer in men after skin cancer.1 The American Cancer Society estimates that approximately 233,000 new cases of prostate cancer will be diagnosed and approximately 29,480 men will die of the disease in 2014.1 Although most prostate cancer is caught early and often successfully treated, a significant percentage of men eventually progress to advanced disease.1 Fortunately, recent studies have demonstrated that these men are now living longer than ever.2,3 Although this is encouraging, managing the disease over a longer period of time may create physical and emotional burdens, impacting the quality of life for both patients and their caregivers. A recent national survey of men with advanced prostate cancer and the caregivers of men with advanced prostate cancer sheds light on some of the needs, concerns, and priorities related to coping with the disease long-term and suggests how health care professionals may help patients and caregivers manage them. Astellas Pharma US Inc and Medivation Inc commissioned the Advanced Prostate Cancer Patient and Caregiver Burden of Illness Survey through the research firm Harris Interactive, and sponsored four leading cancer advocacy and education organizations to collaborate on the initiative: the Association of Oncology Social Work, CancerCare, Prostate Health Education Network (PHEN), and Us TOO Prostate Cancer Education & Support Network. Survey data are not weighted, and

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FEATURE | Coping with prostate cancer thus are only representative of people who qualified for and completed the survey. For the purposes of this survey, caregivers was defined as anyone in regular contact with qualified patients who assist with their care and/or help them make treatment decisions. A NATIONAL SURVEY: THE RESULTS A total of 91 men, age 60 years and older, with advanced prostate cancer and 100 caregivers of men with advanced prostate cancer completed the survey, which was designed to evaluate the physical and emotional impact of advanced prostate cancer on both patients and caregivers. More than 50% of the patient respondents reported living with a prostate cancer diagnosis for at least 6 years and nearly one-third (33%) reported living with a diagnosis for more than 10 years. Caregivers who participated in the survey reported an average caregiving duration of nearly 5 years. Sixteen percent reported that they have been providing care for more than 8 years. Thirty-eight percent of caregivers reported caring for a father, 23% for a spouse/partner, 12% for a grandfather, 10% for a father-in-law, 9% for a friend, and 5% for another relative. Patient concerns Patient respondents to the survey expressed the most concern around their ability to continue living their lives fully and about becoming a burden. Sixty-three percent of patients who participated in the survey said they are concerned or very concerned about their ability to continue participating in the activities they enjoy, and 59% expressed this same level

Patients expressed the most concern around their ability to continue living their lives fully and about becoming a burden. of concern around becoming a burden to their family and friends. By comparison, 43% of patient respondents reported having the same level of concern about dying. Patients who participated in the survey also expressed loneliness and feelings of isolation. Forty-one percent of patient participants said they do not feel like people understand what they are going through in terms of managing and treating their prostate cancer, and 45% reported they keep silent about their prostate cancer and treatments. Although many patient respondents reported feeling hopeful about their disease (58%), the greatest percentage said their disease makes them feel uncertain (62%). Among other responses, 33% said

they feel fearful, 32% feel sad, and 20% feel lonely or alone. Patient participants reported conflicted feelings with regard to the information that is available to them. They said they are eager for the information, yet more than one-third of the patients (35%) said there is too much information available about prostate cancer to understand it all. Caregiver concerns Caregivers who participated in the survey—some of whom are elderly themselves (19% were 65 years and older) or have full-time work/family responsibilities—expressed a high degree of stress associated with their roles. Eighty-five percent reported that caring for someone with prostate cancer created stress/anxiety in their day-today life related to the patient’s well-being, and 73% said there are days when they feel overwhelmed caring for someone with advanced prostate cancer. Caregivers also expressed anxiety about their long-term caregiving responsibilities. Among the caregivers surveyed, 73% said they are concerned or very concerned about their ability to continue providing care over a long period of time. Similar to the patient survey respondents, caregivers expressed interest in having more information available to them. In terms of information priorities, 64% of caregiver participants said they strongly agree that they would like more information about treatment options available, 53% want to know how to help their loved one cope with the physical side effects of treatment, and 51% want to understand how specific treatments work in the body. In addition, caregivers demonstrated a clear need for additional support as well as guidance around where/how to find desired information: 47% of caregivers said there is too much information about prostate cancer to digest it all, but 86% of caregiver participants said they would like more information to be available to them. IMPLICATIONS FOR ONCOLOGY PROFESSIONALS Findings from the Advanced Prostate Cancer Patient and Caregiver Burden of Illness Survey highlight several critical issues that oncology nurses should consider to help improve the health and well-being of both patients and their caregivers. As men with advanced prostate cancer live longer, quality of life becomes the central issue for many of these men, and there is a need for further research in this area. Research needs to further define the issues that these men are struggling with and how health care professionals can address them. In the meantime, if men with advanced prostate cancer are primarily concerned with the ability to care for themselves (not becoming a burden) and participating in the activities of life that are meaningful to them, the health care team should aim to help preserve that level of function for as long as possible. The findings from this survey also suggest that

28 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014 • www.OncologyNurseAdvisor.com

Both groups of respondents expressed concern about navigating information about their illness and treatment. patients and their caregivers need help and support to deal with the stress and demands of living with a serious illness. Nurses play a key role in helping these patients: 43% of patients surveyed rated their oncology nurse as important or very important in helping them make decisions about prostate cancer treatment. A 2012 Gallup poll showed that, for the 12th year in a row, nurses were perceived as the most honest health care professional amongst pharmacists, medical doctors, dentists, psychiatrists, and chiropractors.4 Given the degree to which patients rely on and trust their nurses, these professionals may play a critical role in helping patients understand that their feelings are normal and allowing them to verbalize their experience. As we all know, caregivers need support as well. These survey findings showed that caregivers often prioritize their patient over their own health and well-being. Nurses should encourage patients to include their caregivers in visits with their health care professional. In that way, caregivers can be encouraged to seek support for themselves and care for their own needs because providing support effectively is difficult when feeling overwhelmed and/or experiencing stress and anxiety.

This could then empower patients and caregivers to feel they are making better-informed decisions. As experienced educators and advocates, nurses can help patients with advanced prostate cancer and their caregivers understand that they are not alone, while offering excellent, high-quality education and resources to help them deal with the many issues they are facing. In addition to providing in-office support, a good way to help patients and caregivers is to encourage them to access appropriate, trusted resources such as Us TOO Prostate Cancer Support & Education Network, the Prostate Health Education Network, or CancerCare for information about their disease, help coping with the disease, and ways to connect with other people in similar situations. Nurses can provide help and hope to preserve the highest quality of life for these men and their caregivers. ■ Acknowledgement Editorial assistance was provided by Astellas Pharmaceuticals Inc and Medivation Inc. Jeffrey Albaugh is a board certified Urology Clinical Nurse Specialist and the Director of Sexual Health at the John & Carol Walter Center for Urological Health at NorthShore University HealthSystem in the Chicago area. REFERENCES 1. Prostate Cancer. American Cancer Society Web site. http://www.cancer. org/cancer/prostatecancer/index. Accessed April 16, 2014. 2. Omlin A, Pezaro C, Mukherji D, et al. Improved survival in a cohort of trial participants with metastatic castration-resistant prostate cancer demonstrates the need for updated prognostic nomograms. Eur Urol.

INFORMATION OVERLOAD

2013;64(2):300-306.

In this study, both groups of respondents also expressed concern about accessing and navigating information about their illness and treatment. Although a vast amount of information is available for both patients and caregivers, it is difficult to identify credible and trustworthy sources of evidence-based medical information. Oncology nurses have an opportunity to help patients and their caregivers traverse the available information and determine what is accurate.

ON THE

WEB

3. Mukherji D, Pezaro CJ, Shamseddine A, De Bono JS. New treatment developments applied to elderly patients with advanced prostate cancer. Cancer Treat Rev. 2013;39(6):578-583. 4. Newport F. Congress retains low honesty rating: Nurses have highest honesty rating; car salespeople, lowest. Gallup Politics Web site. http:// www.gallup.com/poll/159035/congress-retains-low-honesty-rating. aspx. Published December 3, 2012. Accessed April 16, 2014. 076-0207-PM 4/14

Robotic surgery trends create new career options for nurses Dan Neel

Issues in Cancer Survivorship Conflicts in spirituality: Why me versus why not me Bette Weinstein Kaplan

For these features and more, go to www.OncologyNurseAdvisor.com

www.OncologyNurseAdvisor.com • MAY/JUNE 2014 • ONCOLOGY NURSE ADVISOR 29

STAT CONSULT Obinutuzumab (Gazyva) Drug type

• A CD20-directed cytolytic monoclonal antibody Indication

• Treatment of patients with previously untreated

chronic lymphocytic leukemia (CLL), in combination with chlorambucil Mechanism of action

• Obinutuzumab is a monoclonal antibody that targets the CD20 antigen expressed on the surface of pre B- and mature B-lymphocytes • Upon binding to CD20, obinutuzumab mediates B-cell lysis through engagement of immune effective cells, by directly activating intracellular death signaling pathways and/or activation of the complement cascade Dosage and administration

• Premedicate with acetaminophen, antihistamine, and a glucocorticoid before each infusion • Administer via IV infusion • Administered in a total of six 28-day cycles — Cycle 1 ■ Day 1: 100 mg at 25 mg/h over 4 hours ■ Day 2: 900 mg at 50 mg/h, may increase at 50 mg/h every 30 min (max 400 mg/h) ■ Days 8 and 15: 1,000 mg at 100 mg/h, may increase by 100 mg/h increments every 30 min (max 400 mg/h) — Cycles 2 to 6 ■ Day 1: 1,000 mg at 100 mg/h, may increase by 100 mg/h increments every 30 min (max 400 mg/h) Special populations

• Pregnant women — Pregnancy category C

• Nursing mothers — Discontinue nursing or discontinue drug • Pediatric patients — Not established • Elderly patients — No significant differences in efficacy observed between patients 75 years and older and those younger than 75 years • Renal impairment — Not studied in patients with a baseline CrCl <30 mL/min • Hepatic impairment — Not studied in patients with hepatic impairment Black box warnings

• Hepatitis B virus (HBV) reactivation, in some cases resulting in fulminant hepatitis, hepatic failure, and death can occur in patients receiving CD20-directed cytolytic antibodies. • Progressive multifocal leukoencephalopathy (PML) including fatal PML, can occur in patients receiving obinutuzumab Warnings/Precautions

• Closely monitor patients during the entire infusion. Reactions have occurred within 24 h of receiving obinutuzumab — Grade 1 or 2 infusion reactions: Interrupt or reduce the rate of the infusion and manage symptoms — Grade 3 infusion reactions: Interrupt infusion until resolution of symptoms

30 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014 • www.OncologyNurseAdvisor.com

——Grade 4 infusion reactions: Stop infusion and discontinue permanently • Preexisting cardiac or pulmonary conditions ——Monitor more frequently for severe reactions ——Hypotension may occur ——For patients at increased risk of hypertensive crisis, consider the benefits versus the risks of withholding their hypertensive medication • Hepatitis B virus reactivation ——Screen all patients for HBV infection prior to initiating treatment ——Immediately discontinue obinutuzumab and any concomitant medications in the event of HBV reactivation ——Monitor HBV-positive patients during and after treatment • Progressive multifocal leukoencephalopathy ——Discontinue treatment and any concomitant chemotherapy/immunosuppressives if PML develops • Tumor lysis syndrome ——Can occur within 12-24 h after the first infusion ——Risk greater in patients with high tumor burden and/ or high circulating lymphocyte count (>25 × 109/L) ——Prophylaxis with antihyperuricemics and hydration beginning 12-24 h prior to infusion • Infections ——Serious bacterial, fungal, and new or reactivated viral infections can occur during and following treatment. ——Do not administer obinutuzumab to patients with an active infection • Thrombocytopenia ——Severe thrombocytopenia can occur ——Grade 3 or 4: Monitor platelet counts and bleeding frequently until resolution ——Management of hemorrhage may require blood product support • Neutropenia ——Severe neutropenia can occur ——Grade 3 to 4: Monitor patients frequently with regular laboratory tests until resolution ——Can be late onset and/or prolonged ——Administration of antimicrobial prophylaxis is strongly recommended throughout the treatment period Adverse effects

• Common adverse effects (occurs in ≥10% of patients) ——Anemia ——Cough

——Infusion reactions ——Musculoskeletal disorders ——Neutropenia ——Pyrexia ——Thrombocytopenia • Serious adverse effects ——Hepatitis B reactivation ——Infections ——Progressive multifocal leukoencephalopathy ——Tumor lysis syndrome Drug interactions

• Concomitant live viral vaccines: Not recommended • Withhold antihypertensives for 12 h prior to, during, and for 1 h after infusion until BP is stable What to tell your patient

• Your doctor has prescribed obinutuzumab to treat your chronic lymphocytic leukemia. • Tell your nurse and doctor if you have a cardiac (heart) or pulmonary (lung) condition. You may be at greater risk of experiencing more severe reactions. • Tell your nurse and doctor if you are taking medication for hypertension or high blood pressure. ——Your doctor may ask you to not take your blood pressure medication for 12 hours before receiving obinutuzumab and for 1 hour after the infusion is complete, until your blood pressure is stable. • Tell your nurse or doctor if you have a history of chronic or recurrent infections. • You should not take this medication if you have an active infection. • Your doctor will order laboratory tests of your blood to monitor for potential effects of obinutuzumab such as neutropenia (low white blood cell count) and thrombocytopenia (low platelet count). • Tell your nurse or doctor if you have recently received or are scheduled to receive a vaccine. ——You should not receive a live virus vaccine during treatment. • Tell your nurse or doctor right away about any side effect you experience. Obinutuzumab can cause side effects that may become severe or life threatening. • Remember that your doctor has prescribed this medication for you because he or she feels the benefits to you are greater than the potential harms. Continues on page 51

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RADIATION & YOUR PATIENT

©THINKSTOCK

Breaking the silence on treatmentrelated sexual dysfunction Bryant Furlow Sexual dysfunction is a common and distressing side effect of prostate cancer treatment. Two new reports from randomized clinical trials offer mixed results for adjuvant pharmacotherapy intended to prevent erectile dysfunction in men undergoing radiotherapy for prostate cancer. Despite its success in treating erectile dysfunction after it has already emerged, one study found that tadalafil does not prevent the loss of sexual function during radiotherapy. But a separate study suggests that daily sildenafil citrate therapy helps to prevent radiotherapyassociated erectile dysfunction and declines in libido. Early and continuing communication about potential sexual side effects associated with prostate cancer radiotherapy is important and frequently welcomed by patients.

rectile dysfunction, declines in libido and enjoyment of sex, altered orgasm, loss of ejaculation, testicular atrophy, and other sexual changes can contribute to—and be exacerbated by—the anxiety and fatigue associated with prostate cancer and its treatment.1-4 Radiotherapy, alone or in combination with other interventions, is associated with erectile dysfunction, and 40% of men report erectile dysfunction after undergoing prostate radiotherapy.1 Physical changes and body feminization (reduced muscle mass, female weight gain patterns, hot flashes, hair loss) can impact patients’ self-esteem and body image, although these appear to be more associated with androgen blockade than radiotherapy per se.2 Neoadjuvant androgen blockade hormone therapy plus radiotherapy, but apparently not radiotherapy alone, can result in penile shortening.5,6 The mechanisms underlying the association between radiotherapy and erectile dysfunction are not yet well-understood, but appear to involve damage to penile vasculature and smooth muscle, endothelial dysfunction, and fibrotic scarring.1 Pharmacotherapy with phosphodiesterase type 5 inhibitor (PDE5) drugs, such as tadalafil (Cialis) or sildenafil citrate (Viagra), are used to treat erectile dysfunction after radiotherapy, and may work in part because they reduce endothelial dysfunction.1 Interest in PDE5 pharmacotherapies’ value as a prophylactic against the emergence of erectile dysfunction during radiotherapy led to two recently reported randomized prospective clinical trials. One of these, a multicenter placebo-controlled, double-blind, randomized study of 221 evaluable study participants with intact erectile function before radiotherapy, yielded disappointing results: daily tadalafil administered during external-beam

32 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014 • www.OncologyNurseAdvisor.com

or brachytherapy radiotherapy over 24 weeks did not prevent the loss of sexual function at 28 to 30 weeks, compared with placebo (79% vs 72%; P = .49).1 At 1-year follow-up, erectile dysfunction rates were nearly identical between the men assigned to receive tadalafil and those in the study’s placebo group (28% vs 29%).1 Nor was daily tadalafil associated with improved overall sexual function or sexual and marital satisfaction.1 Study participants had not undergone androgen blockade within the past 6 months, so the results appear to specifically address radiotherapyassociated sexual dysfunction.1 Based on their findings, the team concluded that use of PDE5 inhibitors to prevent erectile dysfunction after highly conformal external radiotherapy or lowdose-rate brachytherapy is not supported.1 However, the authors acknowledged that a different dosing regimen (their study employed tadalafil 5 mg daily) or use of another PDE5 drug could yield different results.1

Psychosexual consequences of prostate cancer treatments are often unanticipated among patients. Indeed, a similar study of another PDE5 drug, sildenafil, administered before, during, and after radiotherapy for prostate cancer, seems to offer reason for continued hope that PDE5 can prevent radiotherapy-associated erectile dysfunction.7 That study, supported in part by Pfizer, found that adjuvant

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RADIATION & YOUR PATIENT daily sildenafil citrate during and after radiotherapy better preserved erectile function at 12-month follow-up than did placebo (73% vs 50% reporting mild or no erectile dysfunction; P = .024).7 Men in the sildenafil group also reported modestly significant higher sexual desire scores (P = .049).7 At 2 years after initiation of treatment, erectile function remained better among men who had taken adjuvant sildenafil (82% vs 56%; P = .045).7 COMPLEX UNDERPINNINGS

Some researchers have argued that an emphasis on pharmaceutical monotherapy for erectile dysfunction reflects a fundamental flaw in assumptions about sexual dysfunction following prostate cancer treatment.2,8 Such approaches run the risk of neglecting other facets of the complex and multifactorial psychosexual roots of sexual dysfunction among men with prostate cancer. And that can obscure the potential of other promising interventions. A small but growing body of evidence suggests physical exercise addresses several underlying risk factors that might help improve libido and sexual activity among men with prostate cancer.2 Preliminary findings suggest that these include reduced body feminization, particularly increased muscle mass and more typically masculine body fat distribution; reduced fatigue, depression, and anxiety; increased aerobic capacity and stamina; and improved overall quality of life.2 COMMUNICATION IS KEY

Psychosexual consequences of radiotherapy and other prostate cancer treatments are well known to clinicians but are frequently unanticipated among patients and their partners.8 Sildenafil has been available since 1998, and has improved men’s willingness to discuss post-cancer therapy sexual dysfunction and treatment options with their doctors.9

Yet, studies show clinicians tend to avoid talking about sexual dysfunction with their patients.8,9 “Our study illustrates that health care professionals have the potential to do much more to prepare men and their partners for these impacts,” Liz Forbat, PhD, lead author of one such study,8 told Oncology Nurse Advisor. Her team’s study found that even though partners frequently participate in urology and radiotherapy consultations, they are rarely involved directly in discussions; sexual functioning and wider psychosexual concerns were rarely discussed.8 “Clinicians often worry that asking about sexual functioning may ‘open a can of worms,’ leaving the patient and partner feeling overwhelmed, and the clinician unable to offer adequate support and advice,” explained Forbat, who is codirector of the Cancer Care Research Center at the School of Nursing, Midwifery and Health at the University of Stirling, in Scotland. Tools such as the Expanded Prostate Cancer Index Composite (EPIC) questionnaire can help assess men’s physical function and distress, and it can also serve as a useful way to initiate discussions about sexual function. “Importantly, this tool provides health care professionals with a structure for opening up conversation about the most intimate impacts of prostate cancer treatments,” Forbat said. “Clinicians can then ask gentle exploratory questions about items on the tool where the man identifies difficulties, and this can be very powerful in clinicians identifying potential solutions.” Research including her team’s study “demonstrates that patients often welcome the opportunity to talk about the impact on their sexual functioning, and the ‘can of worms’ looks less worrying when the lid has been lifted,” Forbat said. ■

REFERENCES 1. Pisansky TM, Pugh SL, Greenberg RE, et al. Tadalafil for prevention of erectile dysfunction after radiotherapy for prostate cancer: the Radiation Therapy Oncology Group [0831] randomized clinical trial. JAMA. 2014;311(13):13001307. doi:10.1001/jama.2014.2626. 2. Cormie P, Newton RU, Taaffe DR, et al. Exercise therapy for sexual dysfunction after prostate cancer. Nature Rev Urol. 2013;10(12):731-736. doi:10.1038/nrurol.2013.206. 3. Obayomi-Davies O, Chen LN, Bhagat A, et al. Potency preservation following stereotactic body radiation therapy for prostate cancer. Radiat Oncol. 2013;8:256. doi:10.1186/1748717X-8-256. http://www.ro-journal.com/ content/8/1/256. Accessed May 7, 2014. 4. Bhattasali O, Chen LN, Woo J, et al. Patientreported outcomes following stereotactic body radiation therapy for clinically localized prostate cancer. Radiat Oncol. 2014;9:52. doi:10.1186/ 1748-717X-9-52. http://www.ro-journal.com/ content/9/1/52. Accessed May 7, 2014. 5. Haliloglu A, Baltaci S, Yaman O. Penile length changes in men treated with androgen suppression plus radiation therapy for local or locally advanced prostate cancer. J Urol. 2007;177(1):128-130. 6. Park KK, Lee SH, Chung BH. The effects of long-term androgen deprivation therapy on penile length in patients with prostate cancer: a single-center, prospective, open-label observational study. J Sex Med. 2011;8(11):3214-3219. doi:10.1111/j.1743-6109.2011.02364.x. 7. Zelefsky MJ, Shasha D, Branco RD, et al. Prophylactic sildenafil citrate for improvement of erectile function in men treated by radiotherapy for prostate cancer. J Urol. In press. doi:10.1016/j.juro.2014.02.097. 8. Forbat L, White I, Marshall-Lucette S, Kelly D. Discussing the sexual consequences of treatment in radiotherapy and urology consultations with couples affected by prostate cancer. BJU Int. 2012;109(1):98-103. doi:10.1111/j.1464-410X.2011.10257.x. 9. Furlow B. Sexual dysfunction in patients with lung disease [published online ahead of print

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

40 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014 • www.OncologyNurseAdvisor.com

May 2, 2014]. Lancet Respir Med. doi:10.1016/ S2213-2600(14)70081-5.

C101: EMPOWER YOUR PATIENT

Sarah Krüg

Although technology serves as a catalyst in empowering the patient, digital is not implicit in the definition of an e-patient.

he digital age has facilitated engagement and empowerment, as e-patients use resources to gather information, obtain support, and connect with one another. But what is an e-patient? E-patients are empowered health consumers who are • Engaged in their care • Educated on their condition • Equipped with a skillset to manage their condition • Enabled to make informed decisions • Experts on their day-to-day lives • Equal partners in the circle of care Although technology serves as a catalyst in empowering the patient, digital is not implicit in the definition of an e-patient. A patient can be empowered without being Internet-savvy; although, online resources and connections on the Internet can facilitate empowerment. EXPERTISE OF THE PATIENT Clinicians have traditionally been drivers of health care, whereas patients were merely passengers. The clinician-patient relationship was somewhat paternalistic based on the clinician’s expertise. In this case, the physical illness or symptoms may have been treated, rather than the whole complex patient. However, the traditional medical model has been disrupted by the emergence of the e-patient and an evolving patient-centered landscape. Patients are now recognized for the unique expertise they provide. Today, the e-patient owns their chronic disease, and the clinician-patient relationship is based on a shared expertise. In the patient-centered model, the

patient and clinician are partners in determining care where the clinician’s medical expertise is combined with the patient’s day-to-day life expertise to determine the most appropriate treatment pathway based on the needs, preferences, and barriers of the patient. E-patients are patients who take an active role in managing their health. Patients who have a comprehensive understanding of their condition and of the health system can have a greater sense of control. Arming patients with skills to manage their condition can also provide them with a sense of self-efficacy. Combined, that sense of control and selfefficacy can facilitate communication with the health care team and collaboration on decisions that impact the patient’s care. Ultimately, the patient is empowered as a key partner on the health care team. Patients can play a significant role in improving their care by • Understanding the cause of their disease and factors that influence health • Making informed choices about their care through an understanding of risks and benefits • Sharing decisions about treatments aligned with needs and preferences • Managing medications appropriately • Monitoring and managing symptoms • Observing and checking care processes, including accuracy of medical records • Adopting healthy behaviors to prevent occurrence or recurrence of disease. EVOLVING LANDSCAPE Patient-centered interventions are on the rise as an emphasis is being placed on

www.OncologyNurseAdvisor.com • MAY/JUNE 2014 • ONCOLOGY NURSE ADVISOR 41

C101: EMPOWER YOUR PATIENT

The health care team can empower patients to take a more active role in their care by igniting a participatory relationship.

empowering the patient and the caregiver. In the IOM Report Best Care at Lower Cost, a characteristic of a continuously learning health care system was defined as establishing patient-clinician partnerships through engaged and empowered patients.1 Specifically defined, the report emphasized, “A learning health care system is anchored on patient needs and perspectives and promotes the inclusion of patients, families, and other caregivers as vital members of the continuously learning care team.”1 In a subsequent IOM Report, Delivering HighQuality Cancer Care: Charting a New Course for a System in Crisis, the engaged patient was identified as a key component of a high-quality cancer care delivery system that supports patients in making informed medical decisions aligned with their needs, values, and preferences in consultation with their clinicians, who have expertise in patient-centered communication and shared decision making.2

Importantly, clinicians should recognize the variation in e-patients’ knowledge and skill sets. The health care team can empower patients to take a more active role in their care by igniting a participatory relationship. A simple checklist of “10 Things Every Patient Needs to Know” can help patients become more empowered. What steps are you taking to empower your patients? What would you add to this list? ■ Sarah Krüg is CEO of Cancer101.org. REFERENCES 1. Committee on the Learning Health Care System in America; Institute of Medicine; Smith M, Saunders R, Stuckhardt L, McGinnis JM. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press; 2013. 2. Levit LA, Balogh EP, Nass SJ, Ganz PA, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press; 2013.

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COMMUNICATION CHALLENGES

Peter Rabbit & Mrs. McGregor’s pie Ann J. Brady, MSN, RN-BC “Now, my dears,” said old Mrs. Rabbit one morning, “you may go into the fields or down the lane, but don’t go into Mr. McGregor’s garden. “Your father had an accident there; he was put in a pie by Mrs. McGregor.”1

Oh my, I thought. If Mr. Rabbit was put into a pie, I knew what that meant; how would I explain it to Jake? But he didn’t stop me to ask for clarification. If he didn’t make the connection, should I? I paused for a moment, then turned the page and continued reading.

We knew the futility of more chemo ... But the signs that were obvious to us were not apparent to Henry.

ave you had a patient or family of a patient who seems to know the diagnosis and prognosis, yet they react as if they do not completely understand? How do you handle a situation like that? “That one, Mommy.” Jake pointed to the book we’d bought that afternoon, The Tale of Peter Rabbit by Beatrix Potter. I picked up the book, thinking I must have read it as a child, though I did not remember much of it. We settled onto the couch, and Jake leaned against me. He pointed to the beautiful picture on the cover and we talked about the funny jacket worn by the rabbit. I opened the book and started to read with as much enthusiasm and animation as I could. We laughed over the names of the rabbit children: Flopsy, Mopsy, and Cottontail, but especially over the rabbit named Peter because that was Grandpa’s name and didn’t he have big ears too? I was enjoying our time together when I read the next paragraph:

CASE As I interacted with a patient and her family recently, I remembered the day I read the story to Jake. Cindy had metastatic breast cancer and was hospitalized with delirium and pain. On admission, her calcium was 14 mg/dL. At home, she had a rapid deterioration in her mental status and an increase in her pain. Her family brought her to the ED, and she was admitted. She arrived on the oncology unit in fragile but stable condition. The medical oncologist was clear with them about her disease progression. Cindy was not a candidate for further treatment. She was too weak; her performance status was too low. I heard him say, “She isn’t doing well. I recommend hospice.” He used a concrete but gentle approach. Everyone nodded. Cindy’s family knew she would die from her cancer; that part was clear, but oddly, it was the steps in between that confused them. They were focused on more chemo, believing all of her other problems would be resolved if she had more chemo. Henry, her husband, said, “The chemo helped before. If she gets more

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COMMUNICATION CHALLENGES

[The family] may have understood what would happen in the end but not how Cindy would get there.

chemo then she can get stronger again.” In his mind, the oncologist was not listening. The medical oncologist recommended a palliative care consult to help with this “difficult” family. I’ve heard it said, “There are no difficult patients, only difficult situations.” This was a difficult situation. We arrived in time to hear the end of the conversation between the family and the doctor. The oncologist excused himself and all of us watched as he walked away. Henry said to us, “That doctor makes me so mad.” He paced the room, ran his hands through his hair. He stopped pacing and stood on the far side of Cindy’s bed, gripping the side rails tightly and repeated what we heard him tell the doctor. We knew the futility of more chemo and the negative consequences. But the signs that were obvious to us were not apparent to Henry. When the medical oncologist said Cindy was not doing well, Henry did not disagree. He knew she would die from her cancer, but he had missed some of the steps in between. But before we could get to the details of that middle ground, we needed to allow the family to voice their frustration. What the family wanted differed from what the medical oncologist recommended. To traverse the impasse required the palliative care team to reassess what the family understood. Since Cindy had had a response to chemo, her family was focused on her resuming chemo and struggled to accept that it was no longer an option. As in the story of Peter

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Go to OncologyNurseAdvisor.com/challenges_ understanding to join the conversation on how you help patients’ families who do not understand what is happening to their loved ones.

Rabbit, the middle part was missing. They may have understood what would happen in the end but not how Cindy would get there; they had no understanding of the physiologic cues we saw. Once they had a chance to air their concerns, the meeting shifted to a discussion of Cindy’s current situation. The impact of her hypercalcemia was explained and what it portended, as well as an explanation of her performance status, contextualizing the details and teasing out the parts they seemed to comprehend but actually did not. DISCUSSION When I read the Peter Rabbit story to Jake, he did not question the part about Mrs. McGregor’s pie. I moved on. I think the same thing can happen in our conversations with patients and families. We know the disease process and place a high value on being straightforward in our explanations. Just as the oncologist was gentle and concrete at the same time, we do the same, conveying information and assuming a certain level of understanding. After all, if they don’t ask for clarification then it must be clear. But what if they hear the news without realizing they don’t understand? Not asking questions does not necessarily indicate understanding. It’s like turning the page to continue reading. The middle part, Cindy’s physical condition, was explained in clear detail. It wasn’t exactly an “a ha!” moment as much as it was a resignation, a subtle shift on their part. Labeling a family as difficult or in denial is easy; but in this case, they were just lost. Henry didn’t know that Cindy’s hypercalcemia was an ominous sign, and that her poor performance status could not be reversed. Understanding the middle helped him put the end in context. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California. REFERENCE 1. Potter B. The Tale of Peter Rabbit. New York, NY: Penguin Books; 2002.

44 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2014 • www.OncologyNurseAdvisor.com

ISSUES IN CANCER SURVIVORSHIP

How men used humor to cope with the devastating physical consequences of penile cancer Bette Weinstein Kaplan

sense of humor can be a good thing to have; you never know what it will get your patients through. Cancer of the penis is a good example. Although there is never anything funny about cancer, a group of researchers in England found that humor helped patients make light of their situation. The researchers were curious about “how men with penile cancer construct humor in relation to their diagnosis and treatment.”1 They also looked at how some of the nursing staff used humor in their interactions with patients with penile cancer. Treatment for this rare cancer can leave survivors with difficulty voiding and potentially devastating consequences for sexual functioning. The researchers note that humor is especially useful for a male patient who feels vulnerable in a health care setting. Peter Branney, PhD, and his group at Leeds Metropolitan University in Leeds, United Kingdom, wanted to explore the experiences of men as they went through the diagnosis and treatment process for penile cancer.1 The group used this insight when creating the patient-based information resource healthtalkonline.org. Penile cancer is very rare, and the British group had to work within the limitations of a small sample size. Selection criteria were based on age, disease severity, and type of treatment.

Study participants were 10 men age 35 to 84 years, and primary treatment ranged from a surgical excision of the glans (five patients) to a total penectomy (one patient). COPING MECHANISMS The researchers divided the participants into two focus groups, which enabled them to discuss living with penile cancer. The participants gave the researchers a list of key topics to use in interviews about their disease, and the participants used those topics in subsequent interviews with each other. Thus the focus groups delineated the participants’ priorities, while the interviews went into detail about each man’s experience. The researchers recorded the focus groups and interviews.1 Four themes emerged from their analysis: laughing about urination, humor with health professionals, humor discounted, and fear of ridicule. Laughing about urination Surgical excision of the cancer left the men with a changed anatomy that forced them to change how they performed daily functions. For example, the men could no longer stand up when urinating. Although sitting down to urinate felt abnormal, they were able to make light of the need to sit in a cubicle to urinate. “Because I don’t know which way it’s going to come out.... If I stood up I might shower him at the side of

me.”1 Urinary dysfunction was more tolerable when they could relate their experiences to other men facing the same challenges, and laugh about them. Humor with health professionals

Health professionals reported that they used humor to put the patient at ease.1 One man lost his fear of pain during suture removal because the nurse joked

Anticipation of a lack of empathy among their peers was handled with humor among the participants. with him. Another participant said he joked about having a sex change when he talked with a surgeon prior to his surgery. When the nurses felt comfortable initiating the humor, the patients really enjoyed it. A participant commented, “When you put a bit of a lighter side on it, it just made you feel a little bit better.”1 Humor discounted A humorous approach was not always appreciated. The participants welcomed humor when discussing some aspects of their Continues on page 47

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THE TOTAL PATIENT The Healing Arts Program at Montefiore: A collaboration that heals patients and nurses Bette Weinstein Kaplan

ew York’s Montefiore Medical Center’s Healing Arts Program takes a good thing and makes it better. The program does not restrict the healing arts to patients; it offers the same service to their staff nurses. The Healing Arts Program was founded in 2012 through collaboration between the hospital’s departments of Family and Social Medicine and Human Resources. The program’s aim is to enhance the quality of life and the hospital experience of patients, and also nurses. The program does this by integrating music, creative arts therapies, relaxation techniques, and other healing approaches into programs, clinical services, and education across the medical center.

MUSIC THERAPY Music therapy is one of the most popular services at Montefiore. Six licensed board-certified music therapists who have clinical training provide the music. The clinical training comes into play when the therapist is working with patients, so he or she can understand the interaction from a more psychotherapeutic perspective, while the instruments, voice, and different musical modalities enhance the person-to-person interaction. This provides a perfect therapeutic combination. At the current time, there are six music therapists who offer their music in different ways.

Environmental music therapy Gentle music playing in open clinical spaces is effective in such units as dialysis, ambulatory surgery, and surgical recovery, where patients and family members are very anxious. It is a wonderful way to engage everybody together, and provides a positive distraction that gets people talking about something besides why they are in the hospital.

Montefiore is conducting a 1-year pilot program for nurses on 12 units, including oncology and palliative care. According to Ronit Fallek, MPA, director of the Healing Arts Program, “You’ll hear people talking about the surgery, and suddenly the music therapist starts playing, and people are talking about the music … about memories of favorite songs from the past. It’s a completely different conversation. It shifts the feeling in the room; it changes the conversation and creates a new point of connection. It’s a way for the family members and the patient to feel like themselves,

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like people again. Someone is playing music for them.” Music therapy at bedside When the music therapist comes to the unit, the charge nurse or nurse manager selects the patients to be seen. The therapist always talks with the patients a bit before presenting the music to learn what their favorite music is, and asks them about their memories of favorite songs. They often sing together, and it becomes an enjoyable and humanizing experience. Palliative care also offers the option of doing legacy work, talking about memories and life review. By using the music, therapists help patients communicate through the lyrics and share their stories. Writing songs together In a beautiful activity, the therapist and patient can create something to share with the patient’s family members: a song. Patients often write about their lives or even about what they are thinking at that time. The therapist and patient create a song, and then write a tune for it. They then sing that song together, and even record it. That recorded song can then be shared with the patient and the family as something precious to keep. FOCUS ON ONCOLOGY For oncology patients in particular, in addition to the music therapy described above, Montefiore has a fine artist in residence who devotes several days a week on the center’s various campuses for creating

SOMETHING FOR NURSES, TOO The Healing Arts Program at Montefiore is conducting a 1-year pilot program for nurses on 12 units, including oncology and palliative care. The program utilizes a music therapist and a holistic nurse to deliver individual 30-minute relaxation sessions to nurses on the units. The music therapist uses different musical relaxation techniques, while the holistic nurse utilizes modalities such as guided imagery, breathing, aromatherapy, hand massage, Reiki, and other energy therapies. The hospital’s human resources division sponsors the program.They chose to provide individual half-hour relaxation sessions so only one nurse is off the busy unit

Survivorship Continued from page 45

disease and care, but at certain times, they wanted the straight-man delivery. When told their diagnosis and treatment options, the only thing the men really wanted to hear was their condition was treatable. That lightened the situation for them; humor was discounted. Fear of ridicule The men talked about whom they would tell about their surgery and its consequences. Anticipation of a lack of empathy among their peers outside of the clinical setting was also handled with “inside humor” among the participants.

Kristin Corey, MA, MT-BC, music therapist and coordinator, Healing Arts Program at Montefiore Medical Center, plays the harp.

at a time.Another staff person can cover, and each nurse gets personal time just to sit back and relax. Fallek reports that the responses have been extremely favorable. “Before and after each relaxation session there’s a very short questionnaire asking how stressed and how relaxed each participant is. How stressed are they before, what are their symptoms, and also afterwards? Every 4 months there’s a breakfast on the unit, where the relaxation people just chat with the nurses and the nurse managers. How are you doing? How is it

One participant, who worked in an engineering factory, said, “I would have been scared of it getting out then because men in a factory are a different breed altogether.” Understanding his point, another participant replied, “In other words, they’d have just done nothing but take the piss out of you all day.” “In more ways than one!”1 ENCOURAGE THE USE OF HUMOR The British group concluded that humor can help men with penile cancer to stay positive. These patients may even find something to laugh about among one another and with their

working? What could be done better? At the end of the year-long pilot program there will be in depth interviews to see how successful it was.” Nurses’ comments have been positive. “I really feel different from when I started. The session made me feel calm and peaceful. It put me in a very relaxed mood, which takes me away from everything that is going on around me. It was very therapeutic for me and even removed my shoulder aches!” “The session was very relaxing and helped me connect with my inner thoughts. I felt able to open up and release feelings that have been causing my inability to sleep at night. Concentrating on my breathing helped me focus more. I feel very calm now, with more energy for my work ahead.” Indeed, there are quite a few less stressed nurses who are hoping the Montefiore program is a smashing success, and it will continue. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

health care team when talking about the consequences of their treatment. The researchers also wrote that nurses can use humor to build rapport with patients. However, they caution that nurses should avoid some jokes until after treatment. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Branney P, Witty K, Braybrook D, et al. Masculinities, humour and care for penile cancer: a qualitative study [published online ahead of print February 25, 2014]. J Adv Nurs. 2014. doi:10.1111/jan.12363.

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art with inpatients and outpatients while they are receiving their chemotherapy. The hospital also just received a grant from the Livestrong Foundation to provide a weekly day of music therapy specifically to oncology patients; half the day will be spent with adult inpatients, and half the day will be spent with children at the children’s hospital.

FROM

How to manage cancer and the workplace Anna L. Eckhardt, LCSW

Although the decision to disclose a cancer diagnosis is a personal one, employees need to inform their employer to be protected by the ADA and the FMLA.

ecent advances in treatment and side-effect management are allowing more and more people coping with cancer to continue working during and after treatment. The workplace can be a supportive environment for people facing a cancer diagnosis; it can contribute to a sense of normalcy and provide a feeling of community from colleagues, not to mention financial stability and health insurance benefits. Many working-age adults who are cancer patients must shoulder the tremendous financial strain of their treatment; they have no choice but to continue working or go back to work when they end treatment, regardless of whether or not they feel ready. Patients should be engaged in an open dialogue about their employment status, the decision whether or not to disclose their diagnosis to their employers, and what rights they are entitled to. For many adults who want to continue to work during and after treatment, the issue of disclosure looms large in their minds. Some may worry that they will be seen as a liability to their employer and perhaps be terminated from their position if they disclose their diagnosis. Others, even those who describe themselves as close to their supervisor and colleagues, may fear that they will encounter subtle discrimination. A s an oncolog y socia l worker at CancerCare, I encourage clients who decide to tell their employers about their cancer to learn as much as possible about their diagnosis and treatment schedule before

discussing it. Presenting a plan of action to their supervisor will not only help patients feel more in control of their diagnosis, it may help ease the supervisor’s or coworkers’ concerns about how work will keep moving forward as the patient copes with his or her diagnosis. Part of returning to work after an illness is immersing yourself back into the identity you had before treatment. As part of this, having (and wanting) people to see you as a competent, contributing employee and not just “the one with cancer” is important, but can also be something that can become burdensome. Remind patients not to overextend themselves or fixate on proving to people they can do the job in the same capacity. Instead, encourage them to take control of conversations that become about their cancer by acknowledging their colleague’s comment and then immediately focusing back to work-specific topics. This is called re-casting or resetting your professional image.

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also always remind clients who are seeking employment that a potential new employer does not have the right to ask about medical history. Interviews are about whether you are qualified for the job, and the understandable urge to share cancer history as it relates to their ability to overcome adversity should be avoided. Keep the conversation focused on skills related to the description of employment. Although the decision to disclose a cancer diagnosis is a personal one, employees need

any employers who adhere to ADA guidelines create a flexible work schedule to allow for doctor’s appointments and treatment schedule. Your patients may propose options such as reducing the number of hours they work, telecommuting full-time or part-time, or job sharing. No matter what schedule they agree on with their employer, urge patients to schedule periodic breaks to keep their energy up. In addition, each state has its own Fair Employment Law that can offer even more protection than ADA. Patients can visit www. eeoc.gov to get more information on their state’s Fair Employment Practices Agency. Another key piece of legislation to inform your patients about is the Family and

Medical Leave Act, which provides employees who are affected with a serious illness up to 12 weeks of unpaid, job-protected leave and continued benefits for this period of time. FMLA benefits are available to both patients and caregivers. More information about the benefits and protections of this act is available at www.dol.gov.

erhaps the most important message to impart to your patients is that there are many available resources that can help people coping with cancer in the workplace. CancerCare (www.cancercare.org; 800-813-HOPE [4673]) provides free support services for anyone affected by cancer, including counseling, support groups, and financial assistance. Leading experts in oncology provide up-to-date information on a variety of topics during CancerCare’s free Connect Education Workshops, including topics on coping with cancer while continuing to work and after treatment ends. Cancer and Careers (www. cancerandcareers.org) is another excellent resource for information about coping with cancer in the workplace. You can also refer patients to the Job Accommodation Network (askjan.org), a free service that answers questions about job accommodations, the Americans with Disabilities Act, and related legislation that protects the rights of people coping with cancer in the workplace. Patients who feel they have received unfair treatment in the workplace may wish to contact the Equal Employment Opportunity Commission (www.eeoc.gov; 800-669-4000), a government agency that enforces federal laws prohibiting discrimination based on a person’s race, color, religion, sex, national origin, age (40 years or older), disability, or genetic information. ■

to inform their employer of their status to be protected by the Americans with Disabilities Act (ADA) and the Family and Medical Leave Act of 1993 (FMLA). The Americans with Disabilities Act prohibits discrimination in the workplace related to a disability or a perceived disability, and requires employers to provide reasonable accommodations for qualified employees with a disability. Organizations with 15 or more employees must adhere to ADA guidelines. You and your patients can learn more about this act by visiting www.ada.gov. In order to be protected under the Americans with Disabilities Act, patients must meet the ADA’s definition of a disabled person, be able to perform the job’s essential functions, and not pose a risk to colleagues’ health and safety. Some common workplace accommodations that your patients may wish to explore include modifying their personal workspace to maximize comfort and productivity, or a temporary change in job responsibilities. Encourage patients to work with their supervisor to create a schedule that accommodates their treatment schedule and energy level.

No matter what schedule patients agree on with their employer, urge them to schedule periodic breaks to keep their energy up.

Anna Eckhardt is coordinator of Online Services, CancerCare. www.OncologyNurseAdvisor.com • MAY/JUNE 2014 • ONCOLOGY NURSE ADVISOR 49

THE PATIENT’S VOICE

Nurses’ choices Denise Menonna Quinn, RN-BC, MSN, AOCNS

to my body and feeling an enormous loss of control. That being said, I was becoming the dreaded patient. Before I would let anyone touch me I asked, “Did you wash your hands?” I preferred that they used soap and water, not the hand gel; but I was in too much pain to make the recommendation. Value of communication Fortunately, the nurse who received my report was a colleague and understood my fear of infection. She used all the appropriate communication techniques to alleviate my fears. As fate would have it, my IV infiltrated during transport from recovery to the surgical unit. My nurse, who was also considered the expert on the unit, calmly restarted my IV. She was reassuring and used impeccable technique, as well as utilizing all the safety precautions. Providing care is second nature to nurses; however, this experience made me astutely aware of how patients watch our every move. I always practice excellent hand washing, but after my experience as a patient deeply fearful of infection, I learned to verbally confirm my actions. Now, I tell my patients, “I need to wash my hands,”

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e all have choices. I made the decision to undergo a prophylactic bilateral mastectomy in January 2013, as my grandmother, my mother, and my sister all had breast cancer. The decision was anxiety provoking, but I knew in my heart that I made the right choice and felt grateful that I had a chance to make the choice. My mother did not get a chance to make this choice at 51 years old, and my sister clearly did not have this chance at 40 years old. Nurses face countless choices every day. I chose to arrive at the hospital on July 18, not as a nurse reporting to work but as a patient. On that day, a group of nurses from the pre-op suite to the medical/surgical unit also made choices. They chose to give the patient—me—their best nursing care, yet my experience as a patient taught me invaluable lessons that changed the choices I make as a nurse. Identify yourself Nurses may not think much about the identification badge they wear as part of their professional uniform. That badge, however, is priceless to a patient. I never realized the impact that square piece of plastic has on patients. I found myself immediately looking for the ID badge to see who was walking into the room. That simple piece of our uniform is a lifeline for patients. Although my badge is always visible, I now show it to my patients and tell them who I am. From a nursing perspective, I was a routine mastectomy patient whose care entailed good hand washing, patient education, emotional support, and hopefully, an early discharge. As a patient, however, I was terrified of contracting a hospital-acquired infection and becoming a statistic. I had two drains dangling out of my chest cavity, thinking this is a huge violation

or “Please give me a minute to wash my hands before I touch you.” This also builds immediate trust between the nurse and the patient. Since incorporating this verbal cue, most patients respond with, “Take your time.” Our responsibility as nurses is to make sure the smallest of tasks are executed to the highest standard, and hand washing is one of them. Patience for patients Lastly, I recognized the impact of the nurse-patient relationship, especially when the patient is another nurse. The nursing literature has unfortunately documented how nurses can be unkind to and unsupportive of each other.1 Statements such as “nurses eat their young” are widely recognized clichés.

The nurses who took such good care of me ultimately impacted the care of many more patients. An article on nurse bullying described how technologically savvy new nurses can intimidate older, more experienced nurses.1 It made me think about how the nurse-nurse relationship could impact nurses taking care of nurses. This aspect of nursing may need further research, but my nurses treated me like royalty. Their care was delivered in a kind, compassionate, and empathetic fashion. I remember the OR educator held my hand as he walked me into the operating room, helped position me on the table, and stroked my head until I fell asleep. In conclusion, my experience on the other side of the bed improved my daily practice from the importance of badge identification, reassurance of proper hand washing technique, and understanding nurse-patient relationships. I am proud to say I found that nurses collectively are dedicated, compassionate, and caring professionals. I want to thank the nurses who took such good care of me, ultimately impacting the care of many more patients. ■ Denise Quinn is a nurse transplant insurance coordinator at John Theurer Cancer Center at Hackensack University Medical Center in Hackensack, New Jersey. REFERENCE 1. Thompson G. Nurse bullying: Who’s eating whom? Advance Health

Stat Consult Continued from page 31

• You may experience infusion reactions. These side effects may occur during or within 24 hours of any obinutuzumab infusion. Tell your nurse or doctor if you experience symptoms of an infusion reaction, such as ——Breathing problems, chest pain, chills, diarrhea, dizziness, fever, nausea, and vomiting • Common symptoms you may experience while taking this medication include chills, diarrhea, flushing, headache, hypertension, nausea, pyrexia, and vomiting • This medication can make you more likely to develop an infection. Your doctor may prescribe medications to help prevent infections. Tell your nurse or doctor right away if you develop signs of infection, such as cough or sore throat and/or fever higher than 100.5°F (38°C) • Tell your doctor if you are pregnant, plan to become pregnant, or are breastfeeding. ——It is not known if obinutuzumab may harm your unborn baby or pass into your breast milk. ——Women should use an effective birth control during treatment and for 12 months after treatments are completed. ——Talk to your doctor about discontinuing obinutuzumab if you are breastfeeding. • You should prepare and carry with you a written list of all the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. ——You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. • Obinutuzumab works to break down cancer cells quickly. As cancer cells break apart, their contents are released into the blood which may cause tumor lysis syndrome [TLS]. Your doctor may prescribe medication to help prevent TLS. Symptoms of TLS include diarrhea, nausea, tiredness, and vomiting • If you have a history of hepatitis B infection, obinutuzumab could cause it to return. You should not receive obinutuzumab if you have active hepatitis B liver disease. Your doctor will monitor for hepatitis during and after treatment. • Symptoms such as confusion, dizziness or loss of balance, difficulty talking or walking, or vision problems could be a sign of progressive multifocal leukoencephalopathy (PML); seek immediate medical attention.

Network for Nurses. http://nursing.advanceweb.com/Features/Articles/ Nurse-Bullying-Whos-Eating-Whom.aspx. Accessed April 8, 2014.

Prepared by Joyce Pagán. Reviewed by Diana Ernst, RPh.

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ASK A PHARMACIST

Imatinib and radiotherapy; management of terminal agitation Is combination therapy of imatinib (Gleevec) and radiotherapy safe?

cells to remain in a phase of their growth cycle in which they are more sensitive to the effects of radiation. Due to their differing mechanism of anticancer activity, targeted chemotherapy agents are not typically used in chemoradiation regimens. There is, however, some data to suggest that imatinib may potentiate the anticancer effects of radiation in select cancers1,2; clinical studies of these combinations are ongoing. There is concern that radiotherapy may increase the toxicity of targeted chemotherapy agents. For example, patients receiving radiation to a large portion of their bone marrow may be at increased risk for neutropenia due to the myelosuppressive effects of both treatments. The decision to continue treatment with a targeted agent during radiotherapy is dependent on the risk:benefit ratio for that patient. Many patient- and treatment-specific factors may affect the risks of continuing targeted therapy. Both medical oncology and radiation oncology providers should be involved in the decision to continue treatment.

any factors that may cause agitation, such as uncontrolled pain, noncritical medical devices (eg, feeding tubes), metabolic abnormalities, and any patient discomfort. The patient’s medicines should also be reviewed, as some may cause delirium and contribute to agitation (eg, antihistamines, tricyclic antidepressants). Medications that have been used to manage agitation and delirium include haloperidol, benzodiazepines, and the atypical antipsychotics (eg, quetiapine [Seroquel]).3 Unfortunately, clinical data in this specific setting is limited. When selecting an agent, important factors to be aware of are the administration route for the agent as well as patient-specific factors that may affect tolerability and efficacy, such as renal or hepatic dysfunction, other medical conditions, and drug interactions with other medications. ■ REFERENCES 1. Oertel S, Krempien R, Lindel K, et al. Human glioblastoma and carcinoma xenograft tumors treated by combined radiation and imatinib (Gleevec). Strahlenther Onkol. 2006;182(7):400-407. 2. Choudhury A, Zhao H, Jalali F, et al. Targeting

—Nazanin Nouriany, RN, MScN, CCRP

What would you recommend for a patient with terminal agitation?

homologous recombination using imatinib

Cytotoxic chemotherapy agents have been combined with radiotherapy for many years; this treatment approach is termed chemoradiation. The intent of chemoradiation is to potentiate the effects of radiation on cancer cells and increase cancer cell death. Cytotoxic chemotherapy agents such as the fluoropyrimidines (eg, fluorouracil, capecitabine [Xeloda]), taxanes (eg, paclitaxel [Taxol]), and platinum agents (eg, cisplatin) are the agents typically used for this purpose. These agents increase the anticancer effects of radiotherapy by making cellular DNA more susceptible to damage, interfering with cellular repair, or causing cancer

—Ann Lorden, RN

sitivity and radiosensitivity. Mol Cancer Ther.

results in enhanced tumor cell chemosen2009;8(1):203-213.

Agitation in an end-of-life setting is frequently multifactorial, and can be complicated by the presence of concomitant delirium. Prior to initiating pharmacologic treatments, you should account for

3. Quijada E, Billings JA. Pharmacologic management of delirium; update on newer agents, 2nd ed. EPERC Fast Facts and Concepts. http://www. eperc.mcw.edu/EPERC/FastFactsIndex/ff_060. htm. Accessed May 8, 2014.

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

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