ONA May/June 2017 by Haymarket Media

ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017

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May/June 2017

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

NAVIGATOR NOTES

■ Earn 0.75 and contact Navigation thehours

Development of Cancer FREE CONTINUING Screening Programs EDUCATION INSIDE!

Text here, PAGE xx FEATURE

The Integration of Cannabis in Oncologic HEADER HERE Care Text here

HEADER JOURNAL REVIEW HERE Why Women Opt for Text here Mastectomy vs BCT

HEADER HERE RADIATION & Text here YOUR PATIENT ASTRO Guidelines HEADER HERE for Palliative RT Bone Mets Updated Textofhere

HEADER ISSUES INHERE CANCER SURVIVORSHIP

Text here

Risks of Second Cancers Increased for Hodgkin Lymphoma Survivors

ASK A PHARMACIST VOLUME 8, NUMBER 3

Financial Toxicity: The Impact of Cancer Treatment Costs

SUPPORTIVE CARE

Distress Management: Measuring How Cancer Impacts a Patient’s Life

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www.OncologyNurseAdvisor.com/Navigation This activity is jointly provided by the Oncology Nursing Society and Haymarket Media. This conference is supported by educational grants from AstraZeneca, Bristol Myers Squibb, Celgene Corporation, Genomic Health, Inc., Lilly, Novartis, Novocure, Pfizer, and Tesaro. Target Audience This educational activity is designed to address the needs of nurse navigators, care coordinators, oncology nurses, advanced practice nurses, cancer program administrators, and cancer service line directors involved in the management of people with cancer. Continuing Nursing Education ONS is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Oncology Nursing Society is providing contact hours for this program and maintains responsibility for adherence to ANCC criteria. For more information about the accreditation of this program, please contact the Oncology Nursing Society at 1-866-257-4ONS or help@ons.org.

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Oncology Nurse Advisor (ISSN 2154-350X), May/June 2017, Volume 8, Number 3. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. Oncology Nurse Advisor is available for single copy purchases at the following rates. Price per copy: USA $20; Foreign $30. To order call (800) 558-1703. For advertising sales, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

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 2017 • ONCOLOGY NURSE ADVISOR 5

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CONTENTS 9

IN THE NEWS • Survey Reveals PCP Recommendations for Routine Breast Cancer Screening • Novel Approach Prevents GVHD After Hematopoietic Stem Cell Transplantation • New Criteria for Appropriate Use of Bone Scintigraphy in Prostate and Breast Cancers … and more

IN THE NEWS: ONS 2017 • Guideline-driven Initiative Improves Pneumococcal Vaccination Rates Among aHSCT Recipients • CAR T Cells: Keeping Pace With Adverse Effects of an Emerging Therapy • Nursing Protocol Enhances Care of the Family at End of Life in the Hospital Setting … and more

NAVIGATOR NOTES Navigation and the Development of Cancer Screening Programs

May/June 2017

Diane McElwain, RN, OCN, MEd

FEATURES 24 Distress Management Tool Is Updated to Include Self-Care Megan Garlapow, PhD

45 FIND US ON

The Integration of Cannabis in Oncologic Care Glenn Meuche, MSW, LCSW

Continues on page 8

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STAT CONSULT Vandetanib (Caprelsa)

CONTENTS 28

Vandetanib is a kinase inhibitor indicated for the treatment of symptomatic or progressive medullary thyroid cancer in patients with unresectable locally advanced or metastatic disease.

May/June 2017

JOURNAL REVIEW Optimal Management of Myeloma With Bortezomib John Schieszer, MA

Why Women Opt for Mastectomy vs BCT

PATIENT EDUCATION: FACT SHEETS Chronic Myeloproliferative Neoplasms Treatment This fact sheet examines the various kinds of chronic myeloproliferative neoplasms, and the tests utilized to detect and diagnose them.

John Schieszer, MA

Mammograms

STAT CONSULT Blinatumomab (Blincyto)

This fact sheet reviews the types of mammograms, false-positive and falsenegative results, digital mammography, and tomosynthesis mammography.

RADIATION & YOUR PATIENT ASTRO Guidelines for Palliative RT of Bone Mets Updated Bryant Furlow

COMMUNICATION CHALLENGES “Could Be Worse”: When Patients Minimize Their Cancer Diagnosis Ann J. Brady, MSN, RN-BC

PUBLISHERS ALLIANCE: DOVE PRESS Mastectomy Skin Flap Necrosis: Challenges and Solutions This research discusses the management options for incidents of mastectomy skin flap necrosis (MSFN) Breast Cancer: Targets and Therapy

ISSUES IN CANCER SURVIVORSHIP Study Shows Risk of Second Cancers Increased for Hodgkin Lymphoma Survivors Bette Weinstein Kaplan

42 FROM CANCERCARE Outcomes in Breast Cancer Are Improved With Physical Activity Marissa Fors, MSW, LMSW

45 REFLECTIONS Managing Pain in a Changing Climate

Serum Liver Enzymes Serve as Prognostic Factors in Patients With Intrahepatic Cholangiocarcinoma This study examines the influences of liver enzymes on the overall survival in a number of patients with intrahepatic cholangiocarcinoma (ICC). OncoTargets and Therapy

Tahitia Timmons, MSN, RN-BC, OCN

ASK A PHARMACIST Putting a Name on the Impact of Cancer Treatment Costs Lisa A. Thompson, PharmD, BCOP

8 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

ON THE

WEB

IN THE NEWS Survey Reveals PCP Recommendations for Routine Breast Cancer Screening A national survey highlights primary care physician (PCP) breast cancer screening recommendations in the setting of guideline changes and differences. Professional societies such as the American Cancer Society (ACS), the US Preventive Services Task Force (USPSTF), and the American Congress of Obstetricians and Gynecologists (ACOG) continue to differ in their recommendations on when to start, the optimal interval, and when to discontinue breast cancer screening with mammography. Archana Radhakrishnan, MD, of Johns Hopkins University and colleagues, sought to better understand physician recommendations for breast cancer screening given recent guideline changes and differing recommendations by professional societies. The study included a survey of PCPs that provide care to women aged 40 years or older and included internal medicine, family medicine, and gynecology. Physicians were surveyed on if they typically recommend routine breast cancer screening without a family history of breast cancer in various age groups and intervals. The study had a 52% response rate and respondents were more often white (70.6%) male (54.6%) physicians. Breast cancer screening was recommended for women ages 40 to 44 years, 45 to 49 years, and 75 years or older by 81%, 88%, and 67% of responding physicians, respectively. Annual screening was recommended in the same age groups by 62.9%, 66.7%, and 52.3%, respectively. Gynecologists were more likely to recommend breast cancer screening for women of all age groups compared with internal medicine or family medicine physicians (P <.001). Overall, 26% of the responding physicians reported trusting the ACOG guidelines the most, compared with 23.8% for ACS guidelines and 22.9% for USPSTF guidelines. Physicians who reported trusting ACOG or ACS guidelines more than the USPSTF guidelines were more likely to recommend screening for breast cancer at a younger age.

Integrating Texture Features in Breast Tissue Analysis Improved Accuracy of Tissue Classification A texture analysis technique improved classification of different types of breast tissue imaged with optical coherence microscopy (OCM), a combination of optical coherence tomography and confocal microscopy. OCM provides improved penetration depth compared with confocal microscopy and better resolution than optical coherence tomography. The researchers examined several types of texture features from 46 breast tissue samples; 27 were benign tissue (eg, fibro-

adenoma and usual ductal hyperplasia) and 19 were malignant (eg, invasive ductal carcinoma and carcinoma in situ). The samples were viewed using large-field OCM. Corresponding histological analyses provided ground truth diagnoses. In total, 4310 small OCM image blocks of 500 by 500 pixels, each paired with histology, were extracted from the large-field OCM images. Analyses labeled the smaller images as fat (n = 347), fibrous stroma (n = 2065), breast lobules (n = 199), carcinomas (n = 1127), and background (n = 572). Read more at http://bit.ly/2rnxVET. In the News continues on page 10

www.OncologyNurseAdvisor.com • MAY/JUNE 2017 • ONCOLOGY NURSE ADVISOR 9

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

Survivorship Care Plans Specific to Head and Neck Cancers Enable Transition to Posttreatment Care The Institute of Medicine describes survivorship as a distinct phase of cancer care and recommends that all patients receive survivorship care plans (SCPs). The American College of Surgeons (ACOS) standards require that all patients who undergo curative treatment for cancer receive SCPs on completion of therapy, with 100% adherence expected by 2019. Minoka Hicks, RN, BSN, BA, OCN, and colleagues at Duke Cancer Institute in Durham, North Carolina, sought to determine the early survivorship needs of patients with head and neck cancers to better design disease-specific survivorship care plans. For this study, they gave anonymous needs assessment surveys to patients with head and neck cancer in medical oncology, radiation oncology, and otolaryngology surgery clinics, with a response goal of 30-50 individual patients. The survey queried participants about healthy lifestyle behaviors, their knowledge of late/long term adverse effects, and posttreatment health care follow-up recommendations. Long term/late adverse effects experienced by patients with head and neck cancers include musculoskeletal changes, lymphedema of the neck, xerostomia, dental caries, osteonecrosis, hypothyroidism, and depression/anxiety. Health promotion considerations for SCPs include smoking cessation, alcohol cessation, healthy weight and nutrition, and physical activity/exercise.

As part of the SCP program, the patient’s primary care physican will be included in the recovery process early in order to facilitate the patient’s transition to a healthy lifestyle. Read more at http://bit.ly/2pHRDyR.

Program Developed To Provide Cancer Screening Services for Under/Un-Insured Asian Indio Women The Cancer Outreach Project and the National Indio Cooperative Enterprises, Inc. (NICE) have partnered to provide cancer education, screening, and referral services to Asian Indio women that are culturally and linguistically appropriate. The program focused on Asian Indio Cultural competency women who were either not insured builds patient trust or underinsured and provided services such as a clinical breast examination, Pap smear and pelvic examination, and screening or diagnostic mammography/ ultrasound as appropriate. Participants also received fecal immunochemical testing and referral for colonoscopy as per American Cancer Society guidelines. These services were provided in collaboration between an Asian Indio lay navigator and an advanced practice nurse, and any patients with abnormal test results were referred to the appropriate health care professional for continued services through grant funding. The researchers have since conducted a retrospective review of the outcomes of this program that indicated more than 500 women have received cancer prevention medical services and awareness education. The program’s patient panel included 255 women, the majority of whom return between 2 and 7 years for follow-up care. The program has diagnosed 8 cancers, including ductal carcinoma in situ, lobular carcinoma in situ, stage I breast cancer, stage III breast cancer, in 1 patient each; and cervical cancer and endometrial cancer, in 2 patients each. The researchers understood that the use of outreach methods and health care providers who have similar cultural backgrounds or display cultural competency can improve trust in patient populations and promote follow-up care. The participants in this study specifically indicated their culturally sensitive lay navigator and female health care provider as a factor that encouraged their participation and compliance. Read more at http://bit.ly/2ro5S8o. In the News continues on page 22

www.OncologyNurseAdvisor.com • MAY/JUNE 2017 • ONCOLOGY NURSE ADVISOR 21

In total, 204 wipe samples were collected and analyzed for cyclophosphamide and fluorouracil by an independent laboratory. The analytic limit of detection for each drug was 0.002 ng/cm 2. Cyclophosphamide and fluorouracil were detected in 74% of the baseline wipe samples, with levels of contamination ranging from less than the limit of detection to 3.88 ng/cm2 and 0.36 ng/cm2 for fluorouracil and cyclophosphamide, respectively. After the simulated administration, only 2% of the wipe samples were at or above the level of detection, with 0.003 ng/cm 2 for f luorouracil and 0.002 ng/cm 2 for cyclophosphamide. This difference in samples demonstrated a statistically significant difference when comparing baseline to the closed system drug transfer device (P <.001).

IN THE NEWS | ONS 2017

Historically, nurse quality metrics are identified for infection, errors, falls, and responses to codes; however, such measures are rarely applied to quality of care at the end of life. Deborah Boyle, MSN, RN, AOCNS, FAAN, of University of California Family involvement Irvine Health in Huntington Beach, in final moments California, and colleagues sought to create an evidence-based acute family bereavement support protocol modeled on the perinatal and NICU family interventions when an infant dies. The researchers used a 13-item survey procured from a literature critique of hospice nurse practices to survey families on their preferences for specific nursing interventions during end-of-life care of a loved one in the hospital. They also sought to delineate nurse and family perceptions of quality care at the end of life in the acute care setting. Nurses having contact with family at the end of life were invited to explore and compare impressions that could influence their practice. Predeath interventions included placing a dove sign on the door, ensuring that there were enough chairs in the room for visitors, determining the need to call “No One Dies Alone,” and asking the family about religious or cultural needs. At death and immediately following death, interventions included asking the family if they wanted to assist in the final bathing, prepare a memory keepsake, or perform an honoring ceremony. In addition, nurse managers would plan coverage for the primary nurse to allow the nurse to help the family gather the loved one’s belongings and walk the family to main hospital entrance, and give the family a dove card to show the parking attendant. Read more at http://bit.ly/2pTIcYc.

Standardized Process for Assessing Chemotherapy Appointments Improves Patient Wait Times A nurse-led team at a National Cancer Institute (NCI)designated cancer center sought to reduce their average patient wait time of 49.7 minutes to no more than 30 minutes beyond the scheduled appointment time. To achieve this goal, the interprofessional team identified issues that occur prior to patients’ appointments that contribute to same-day inefficiencies.

Inconsistent preparations for the next day’s patient visits and lack of a structured process for prescreening patients for infusion visits resulted in variable wait times for ambulatory oncology patients at the NCI-designated cancer center, explained Mary Beth Collins, MSN, RN. Partnering with the patient’s primary nurse, the nurse ambulatory clinical evaluation (ACE) team completes an extensive review of the treatment orders, notes, and laboratory test results. The ACE nurse calls the patient the day before the appointment to conduct an assessment for symptoms or toxicities that indicate precluding or modifying the scheduled treatment. The pharmacy ACE team receives a list of those patients who met pre-established criteria for having their infusion drug prepared in advance. On review of the list, the pharmacy ACE team approves preparation of the drugs the evening before the scheduled infusion visits. Use of the ACE program has reduced average wait time for patients to 32.7 minutes. In addition, the early assessment has reduced wasted doses when patients are ineligible for their treatment. Read more at http://bit.ly/2qP1hjp.

Education and Coaching Are Necessary to Treat Oropharyngeal Cancers After Chemoradiotherapy Researchers led by Jennifer Cerar, RN, CRRN, of the Moffitt Cancer Center in Tampa, Florida, created an algorithm to guide the management and follow-up regarding long-term side effects for patients with human papillomavirus (HPV)-positive oropharyngeal cancers after chemoradiotherapy. Patients were educated about side effects and coached on lifestyle management throughout their treatment course, including detailed handouts in their discharge instructions. The researchers also developed an educational tool that patients could access via their electronic health records to assist in their overall understanding of their disease and the management of related side effects. The researchers conducted a literature review that supported the benefits of coaching and education as it relates to improvements in quality of life for patients receiving cancer treatment. Based on that literature review, the researchers claim that the tools and educational interventions that they developed will improve quality of life for HPV-positive oropharyngeal cancers after chemoradiotherapy. Read more at http://bit.ly/2qoZ8te.

22 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

Nursing Protocol Enhances Care of the Family at End of Life in the Hospital Setting

ancer screening programs are an important outreach tool for cancer centers. They seek to identify cancer in patients when it is at its earliest stage and most treatable and also to identify people who are at high risk for cancer and give them the education and guidance to make the most appropriate health care choices. Oncology nurse navigators and care coordinators are uniquely positioned to take on leadership roles in the planning and management of cancer screening programs within their cancer centers/ institutions. Because many navigators work in independent positions, they often have knowledge of system-wide resources in their community. All health care systems and community agencies have marketing/community plans that document their catchment area and the needs within their marketing area; these needs give clues to the types of programs and resources that would be most useful. Local statistics such as high mortality rates in certain cancers and knowledge of population health risk behaviors are examples of communityspecific guides that help administrators and navigators design programs that are best suited to their community. Navigators should use their knowledge of current cancer screening guidelines as well as their strong advocacy skills to suggest needed programs.They also have a unique communication advantage that allows them to discuss ideas and potential programs with a broader audience within their institution, such as surgeons, pulmonologists, medical internists, and family practice physicians. Navigators

Navigation and the Development of Cancer Screening Programs Diane McElwain, RN, OCN, MEd

should use this position to advocate screening opportunities that address specific deficits within each targeted area. Examples of this type of advocacy would be: are inner city women able to access

mammography centers, are people with lighter skin able to access physicians who can check for skin cancer, and in areas with high smoking rates, do patients have access to lung cancer screening. With all this being said, navigators by no means work alone. Identifying community partners for these programs is important — cancer screening programs are strongest when they pool resources from the community. One successful program offered breast health education seminars at African American churches, including navigatorassisted follow-up to schedule women for low cost or free screening mammography.The same navigator can also follow through with the same women for assistance with diagnostic procedures after positive results. Another example is a skin screening program where family practice residents serve as the screeners and a navigator follows up and issues referrals for those with positive results.The navigator also assisted uninsured patients with funding for necessary procedures.These screening programs can address problems in vulnerable and needy populations. Oncology nurse navigators and care coordinators are in a prime position to change attitudes within their cancer center to promote high quality programs that offer vital services within their own communities with the ultimate goal of affecting mortality rates for curable cancers. ■ Diane McElwain is a nurse coordinator at York Cancer Center, York, Pennsylvania, and a member of the Oncology Nurse Advisor Navigation Summit Advisory Board.

Identifying community partners is important — cancer screening programs are strongest when they pool community resources. www.OncologyNurseAdvisor.com • MAY/JUNE 2017 • ONCOLOGY NURSE ADVISOR 23

NAVIGATOR NOTES

FEATURE | Supportive Care

Distress Management Tool Is Updated to Include Self-Care A review of the updated NCCN Guidelines is presented with a look at the newly published Guideline for Patients. MEGAN GARLAPOW, PHD

he distress patients experience upon diagnosis of cancer and through treatment can have far-reaching effects, including impacting successful treatment of the disease. Regardless of the stage at which the disease is diagnosed, distress frequently occurs. At higher levels, distress can impact adherence to medications and treatment protocols. If left uncontrolled, distress can even impact overall survival of patients.1 The National Comprehensive Cancer Network (NCCN) recently published NCCN Guidelines for Patients and NCCN Quick Guide for Distress to encourage patients to speak with their oncology care team about their distress.2,3 Identification of distress symptoms could enable their appropriate and improved management, which in turn could result in improved treatment outcomes. “Many people assume distress is always psychological/emotional in nature. I think it’s most important to convey that distress can come from or be exacerbated by a variety of sources. The assessment of distress, and the response to significant distress, needs to be individually tailored, with a broad conceptualization of what distress is,” explained Teresa Deshields, PhD, ABPP, manager at Alvin J. Siteman Counseling Service, Siteman Cancer Center and clinical associate professor at Washington University School of Medicine in St Louis, Missouri, in an interview with Oncology Nurse Advisor. Deshields is a member of the panel that created the NCCN Distress Guide.

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The American College of Surgeons (ACS) in 2015 required cancer centers to establish a protocol for screening for distress in all patients who receive a cancer diagnosis. NCCN created the initial Distress Thermometer in 1997 and updated it in 2017. The Distress Thermometer, part of the NCCN’s Guidelines for Distress Management, enables self-identification of level of distress on a scale from 0 to 10, similarly to how pain scales work. Patients who report distress scores greater than 4 should receive referrals to providers of various types of care or appropriate support resources. IDENTIFY THE SOURCE OF DISTRESS

The NCCN’s Distress Thermometer meets ACS requirements. The Thermometer contains a problem list consisting of 5 categories from which patients can identify sources of distress. These 5 categories are physical problems, emotional problems, practical problems, family problems, and spiritual/ religious problems. The Thermometer asks patients to respond “Yes” or “No” to subcategories within each of the 5 categories about whether they are experiencing distress within that subcategory. “First, there are differences in the type of support needed at every level of reported distress. That’s what makes the problem list important, as a way to drill down into source(s) of distress. So a patient endorsing physical problems needs a different response than the patient endorsing practical problems,” explained Dr Deshields. “Second, patients reporting higher levels of distress need a more urgent response, just as you would respond more urgently to a patient reporting higher levels of pain. While at lower levels of reported distress, it might be reasonable to provide some relevant education or agree to track the problem over time, in general this shouldn’t be the response for level 9 distress.” TAILOR RESOLUTIONS TO THE CAUSE OF DISTRESS Emphasis remains on “Physical Problems,” which has 22 subcategories, including breathing, diarrhea, fatigue, fevers, getting around, mouth sores, nausea, and pain. Six subcategories in “Practical Problems” include child care, housing, and insurance/financial. The 4 subcategories of “Family Problems” include dealing with partner and ability to have children, and the 6 subcategories of “Emotional Problems” include depression and nervousness. “Spiritual/Religious Problems” exists as its own single point category. Space at the end allows for

patients to inform their oncology care team on areas of distress not covered in the Thermometer. “Any problem area can be disruptive for a patient and can interfere with their ability to participate in treatment. For example, a patient without transportation to medical appointments (or without child care when they have medical appointments) would have difficulty beginning or continuing treatment,” explained Dr Deshields. “Likewise, a patient with significant unresolved physical problems may feel unable or unwilling to continue with treatment, especially if they believe that treatment exacerbates the physical symptoms. Patients with severe anxiety may feel unable to tolerate treatment, especially if their anxiety is worsened by some aspect of treatment (needle phobia, claustrophobia interfering with MRI tests or radiation treatment).” The multifaceted nature of these categories acknowledges that distress arising from diagnosis and treatment affects a wide array of areas of life. By referring patients to care when they experience distress scores greater than 4, ultimately treatment and prognosis can improve as patients are more likely to adhere to medications and therapeutic protocols. BREAKING THROUGH THE BARRIERS Although the ACS requires distress guidelines and the NCCN has readily available guidelines and even more accessible quick guides, obstacles to implementation remain. “Many people assume distress is always psychological/ emotional in nature. I think it’s most important to convey that distress can come from or be exacerbated by a variety of sources. The assessment of distress, and the response to significant distress, needs to be individually tailored, with a broad conceptualization of what distress is,” stated Dr Deshields. In addition to the Distress guideline, the NCCN created guidelines for many different types of cancer, including acute lymphoblastic leukemia, brain cancer and gliomas, breast cancer, colon cancer, esophageal cancer, Hodgkin’s lymphoma, non-small cell lung cancer, melanoma, chronic lymphocytic leukemia, follicular lymphoma, mantle cell lymphoma, ovarian cancer, pancreatic cancer, soft tissue sarcoma, and stomach cancer. ■ Megan Garlapow is a medical writer based in Tempe, Arizona. The references are included in the online version of this article, available through this quick link: http://bit.ly/2rJpdSl.

www.OncologyNurseAdvisor.com • MAY/JUNE 2017 • ONCOLOGY NURSE ADVISOR 25

FEATURE | Integrative Medicine

The Integration of Cannabis in Oncologic Care Increasing acceptance of medical marijuana within the medical community is prompting research on how to integrate it into standard cancer care. GLENN MEUCHE, MSW, LCSW

lthough cannabis is widely used throughout the world for medicinal purposes, it nonetheless remains the center of much controversy and argument. Yet, despite trepidation and uncertainty, studies have revealed an openness of the medical community to the legalization of marijuana for medicinal use. In a 2013 poll of 1446 physicians, 76% of respondents approved the use of marijuana for medicinal purposes, citing their “responsibility as caregivers to alleviate suffering” as the reason for their support.1 SYMPTOM MANAGEMENT The integration of cannabis in oncology and palliative care appears promising in terms of its therapeutic properties to assuage cancer-related pain and physical discomfort. The underpinnings of medical marijuana for symptom management warrant special attention as a patient’s quality of life is often impacted by neuropathy and chemotherapy-induced nausea and vomiting. “Clinically, I have observed that many cancer patients benefit from adding cannabis to their pain regimen,” said Donald I. Abrams, MD, a hematologist-oncologist at San Francisco General Hospital, San Francisco, California, in a review of the medical benefits of cannabis.2 High doses of opiates administered by well-meaning oncologists or palliative care clinicians frequently alter patients’ cognition, leaving them unable to communicate with loved ones at the end of their life. “Many [patients] have successfully weaned

26 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

themselves down or off their opiate dose by adding cannabis to their regimen,” explained Dr Abrams.2 Although opiates are effective in ameliorating pain and discomfort, undesirable side effects of these medications can simultaneously inhibit a patient’s adherence to pain management. The use of cannabis conjointly with opioids may prove advantageous with regard to diminishing some of the side effects that impede a patient’s quality of life. Further research is required, however, to determine the synergism of a cannabinoid-opioid interaction. “If cannabinoids and opioids were shown to be synergistic in a larger follow-on controlled clinical trial, it is possible that lower doses of opioids would be effective for longer periods of time with fewer side effects, clearly a benefit to the patient with pain.”3 The employment of cannabis in cancer care should be recognized as integrative. Patients should proceed with caution before interpreting its use as a front-line defense for pain. “Moving forward to the present moment, I prefer that this type of care be termed ‘cannabinoid integrative medicine’ (CIM), which better contextualizes cannabinoid use within the overarching trends in medicine today. Where integrative medicine blends conventional with complementary and alternative therapy such as botanicals, CIM emphasizes the integrated therapeutic use of the cannabinoid-rich botanical Cannabis,” Sunil Kumar Aggarwal, MD, PhD, of the MultiCare Auburn Medical Center and MultiCare Institute for Research and Innovation, Auburn, Washington, wrote in his article on use of cannabinoids in palliative cancer care.4 EXISTENTIAL AND SPIRITUAL SUFFERING In addition to symptom management, the implications of cannabinoids in oncologic care for mitigating existential and spiritual suffering have been demonstrated as well. This becomes especially significant for patients who may be nearing death and discover themselves addressing endof-life issues. Cannabis can help abate anxiety and promote a sense of peace that is connected intrinsically to a patient’s experience of emotional integrity and spiritual wholeness. Medical marijuana may also be of benefit to terminally ill patients in enabling them to remain engaged in their loved ones’ lives before they die. In speaking about the use of cannabinoid integrative medicine, Dr Aggarwal writes, “Increased awareness of the moment, coupled with the increased introspection and meditation that cannabis can catalyze and for which it has been used in various spiritual traditions, might lead to spiritual growth and development, which can play a vital role in helping people to create a ‘good death’.”4

ADDITIONAL CONSIDERATIONS Some studies have indicated cannabis as an antitumor agent that operates in the induction of apoptosis and prevention of metastasis. “There is evidence that suggests that cannabis may be used as a potential chemotherapeutic treatment. In vivo and in vitro research proposes that cannabinoids can inhibit tumor growth via various mechanisms including increasing cellular apoptosis and suppressing cell proliferation.”1 Although the research is encouraging, patients should not misconstrue these findings as a cure and let them usurp conventional cancer therapy. The results are preliminary and have been focused primarily on animal studies. Dr Abrams, writing with Manuel Guzman, of the Complutense University and Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Madrid, Spain, aptly cautions that “although the in vitro and animal evidence is intriguing, there have not yet been any robust human studies investigating cannabis as an anticancer agent that would warrant advising patients to forego conventional therapy in favor of using a high-potency cannabis extract.”3 CONCLUSION As legislative approval for the use of medical marijuana increases, studies continue to indicate the potential benefits of cannabinoid therapy for palliative and end-of-life care. Its use in oncology appears particularly promising as a viable option for alleviating cancer-related pain. Although further research is essential in determining the influence of cannabinoid integrative medicine on symptom management, caution should be exercised simultaneously, so as not to dissuade physicians from educating their patients on its potential benefits. Exploration and open communication between the patient and physician is therefore crucial. “Integrating CIM into oncologic palliative care promises to improve overall healthrelated quality of life, to further relief from distressing symptoms and spiritual suffering, and to bring hope to patients and families facing terminal illness,” commented Dr Aggarwal.4 Clinicians educated on the benefits of medical marijuana and trained in cannabinoid integrative medicine can initiate the conversation and work toward fostering and ensuing patients’ physical, emotional, and spiritual well-being and dignity. ■ Glenn Meuche is social work internship coordinator at CancerCare. The references are included in the online version of this article, available through this quick link: http://bit.ly/2raMaAO.

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JOURNAL REVIEW

he treatment choices for patients with newly diagnosed myeloma have been evolving and are now significantly different from options available just 5 years ago. Subsequently, the role of the oncology nurse in managing patients with myeloma has also changed significantly. The proteasome inhibitor (PI) bortezomib for the treatment of myeloma was originally used to treat patients with relapsed disease. Today, this agent is used to treat patients with newly diagnosed disease who are both transplanteligible and transplant-ineligible. In addition, bortezomib is considered an important backbone therapy for all stages of the disease, according to a review article published in Cancer Management and Research.1 “In the early studies, dose intensity was considered important (twice weekly dosing via intravenous route). More recent studies have shown a less intensive regimen (weekly dosing via subcutaneous route) enables patients to stay on therapy for many months,” said review author Faith Davies, MD, who is with the Myeloma Institute at the University of Arkansas for Medical Sciences, Little Rock, Arkansas. THE STUDY Approved in 2003, bortezomib was the first PI to demonstrate antimyeloma properties. Dr Davies and her colleagues reviewed some of the key trials that support the use of bortezomib in myeloma in a variety of patients, including those

Optimal Management of Myeloma With Bortezomib John Schieszer, MA on dialysis. “Although bortezomib has been used for a number of years for the treatment of myeloma, a number of recent studies have confirmed its continuing central place in the disease management. The aim of this article is to try and explain how the evidence for its use has developed and to put some of the newer studies in context,” Dr Davies told Oncology Nurse Advisor. For example, newer studies are showing that there may be an advantage with triple therapy with bortezomib compared with dual therapy with bortezomib. However, with these combination therapies, it is vital that proactive steps are taken to prevent grade 1 toxicities from escalating to grade 2 or 3. WHAT WAS LEARNED Dr Davies suggests adopting a proactive management style for addressing peripheral neuropathy and thrombocytopenia

by employing dose delays and reduction strategies. “I think the main message would be that in order for patients to benefit from therapy, management of side effects is key. This is particularly important as we have found that continuous therapy with the drug is often best. The oncology nurse plays a central role in the identification and management of side effects, especially as they have such a special and privileged relationship with the patient,” said Dr Davies. The authors of the review note that the peripheral neuropathy in myeloma patients tends to be predominantly sensory. Some of the symptoms include burning paresthesia, hyperesthesia-hypoesthesia, neuropathic pain, and weakness. Since these neuropathies are reversible, close monitoring and prompt action are vital, according to the authors. They cite the need for quickly making dosing reductions, changing dosing schedules, and adding supportive care. IMPLICATIONS FOR NURSES Dr Davies and her colleagues recommend educating myeloma patients about what symptoms they can expect, and to counsel them that the development of symptoms does not necessarily mean stopping therapy. Dr Davies stressed the importance of explaining to the patients that their symptoms will improve but it can take significant time. “As the survival of patients with myeloma increases, acknowledging that these lower grade side effects are troublesome and that we should try and Continues on page 30

Studies are continuing to show support for prescribing bortezomib for patients with newly diagnosed meyloma, with relapsed disease, with relapsed/refractory disease, and as maintenance therapy. 28 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

JOURNAL REVIEW

he use of thematic maps may help provide greater clues as to why some women with early-stage breast cancer choose breast conserving therapy (BCT) instead of mastectomy, according to Canadian researchers. Their report, published in Clinical Medicine Insights: Oncology, suggests thematic maps may be useful tools for providing visual depictions of decision-making factors. “Experienced oncology nurses have probably come across all of the reasons women choose a therapy brought up in this article. However, the thematic maps introduced in this article may provide a new lens to think about how some women come to their treatment decisions,” said lead study author Jeffrey Gu, MD, who is with the University of Saskatchewan, Saskatoon, Canada.

THE STUDY Studies have demonstrated that breast conserving therapy (BCT) and mastectomy offer equivalent survival in women with early-stage breast cancer (ESBC). Yet, in Canada, mastectomy rates for women with ESBC across the country have varied greatly in recent years. The researchers wanted to better understand why. They explored the decision-making of women in Saskatchewan with ESBC and identified key themes underlying their choice of mastectomy or BCT. For this analysis, the researchers interviewed 13 women who underwent mastectomy and 12 women who underwent BCT.

Why Women Opt for Mastectomy vs BCT John Schieszer, MA

The study showed that women who opted for mastectomy or BCT made their decisions for different reasons. The researchers analyzed data using thematic analysis and developed thematic maps. Three themes emerged among women who opted for mastectomy: concern about cancer recurrence, perceived consequences of BCT treatment, and perception of breast tumor size. Conversely, the women opting for BCT described 3 different themes: mastectomy was too radical, feminine identity, and surgeon influence. “This usually meant the patient asked the surgeon what they would recommend and went with that,” said Dr Gu. WHAT WAS LEARNED Smaller breast and larger tumor size are associated with an increased likelihood of choosing mastectomy. This current study confirmed this finding qualitatively and pointed to new ways of addressing the issue. Women who

opted for BCT in this study considered mastectomy too radical. They also cited recovery time from surgery, perceived tumor size, and confidence in the BCT approach. “The primary goal of this article is to improve understanding of why women with early stage breast cancer choose mastectomy vs breast conserving therapy. With improved understanding, health care providers may be able to deepen their relationships with their patients and provide improved counselling.” Dr Gu told Oncology Nurse Advisor. Fear and worry about cancer recurrence are well-known reasons for why women opt for mastectomy. Dr Gu said this was confirmed, and the current investigation showed that these feelings are related to observed failed BCT, among other things. The most common subtheme was whether a woman had a close family member or friend with ESBC who had a negative BCT or positive mastectomy experience. Dr Gu said oncology nurses through their clinical experiences are uniquely qualified to help guide women during this journey and to offer them insight into some of the pitfalls when weighing the scientific data. Some women may have unwarranted fears that are not being adequately addressed. “Oncology nurses play a vital role in education and counselling in the treatment of breast cancer. The experience they have in interacting with patients and the overall treatment process is invaluable in providing advice

“With improved understanding, health care providers may be able to deepen their relationships with their patients and provide improved counselling,” Dr Gu told Oncology Nurse Advisor. www.OncologyNurseAdvisor.com • MAY/JUNE 2017 • ONCOLOGY NURSE ADVISOR 29

JOURNAL REVIEW

around treatment decisions or dispelling potential misconceptions and fears,” explained Dr Gu. This investigation involved openended questions, and a central theme that emerged was mastectomy was viewed as too radical. The theme of feminine identity was a key reason many women opted for BCT. The women raised issues about body image and seeing themselves as a whole female. IMPLICATIONS FOR NURSES

Treating ESBC is very complicated and involves input on patient preferences and values. However, many other issues also come into play in treatment decisions. The researchers note that this is an

Bortezomib Continued from page 28

recognize them and manage proactively will result in a long-term improvement in quality of life,” explained Dr Davies. She said studies are continuing to show support for prescribing bortezomib for patients with newly diagnosed myeloma, with relapsed disease, with relapsed/refractory disease, and as maintenance therapy. In addition, studies support its use in high risk patients and those with renal failure. Leah Rivas, BSN, RN, a nurse with the Lymphoma/Myeloma service at Roswell Park Cancer Institute, Buff-

FIND US ON

area that has not been well investigated and clinicians have had to primarily rely on quantitative studies examining factors that influence therapy decisions. In addition, these studies have been mostly limited to chart or database reviews and largely retrospective. Dr Gu said thematic maps can be used as educational tools to help women better understand what the clinical data do and do not show among women opting for mastectomy over BCT and vice versa. “The thematic maps are also a clean and simple visual aid that can be used in nursing education. Although these maps were created for only women with ESBC, they can be used as an example of the complexities

that patient’s may face with decisionmaking in the setting of cancer,” explained Dr Gu. Dr Gu said much more work in this area is warranted and the team is engaging in a province-wide survey as the second phase of their study. ■

alo, New York, said oncology nurses play a key role in medication management and ensuring proper medication administration at home, including compliance. She said with myeloma patients pain management can be challenging given the risk of myeloma patients using NSAIDs. “These issues can be managed by educating the patients and caregivers on the disease process, common concerns/ side effects patients experience, and reinforcing the importance of reporting changes to the health care team,” Rivas told Oncology Nurse Advisor. She said the nurse’s role with longterm bortezomib therapy focuses on

symptom management with peripheral neuropathy and teaching interventions to manage symptoms and promote function, while maintaining patient safety. “Many of our patients have benefitted from the use of home/OTC remedies like B complex vitamins and cocoa butter/oil to alleviate some of their symptoms,” said Rivas. ■

John Schieszer is a medical writer based in Seattle, Washington. REFERENCE 1. Gu J, Groot G, Holtslander L, et al. Understanding women’s choice of mastectomy versus breast conserving therapy in early-stage breast cancer [published online February 23, 2017]. Clin Med Insights Oncol. doi: 10.1177/1179554917691266

John Schieszer is a medical writer based in Seattle, Washington. REFERENCE 1. Mohan M, Matin A, Davies FE. Update on the optimal use of bortezomib in the treatment of multiple myeloma. Cancer Manag Res. 2017:9:51-63.

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30 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

STAT CONSULT Blinatumomab (Blincyto) Drug Type

• Bispecific CD19-directed CD3 T-cell engager

Indications

• Philadelphia chromosome-negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL) ——FDA approval is under accelerated approval. Continued approval is contingent upon verification of clinical benefit in subsequent trials. Mechanism of Action

• Blinatumomab binds to CD19 expressed on surface of cells of B-lineage origin and CD3 expressed on surface of T cells • Activates endogenous T cells by connecting CD3 in the T-cell receptor complex with CD19 on B cells • Mediates the following cell activities ——Formation of a synapse between the T-cell and the tumor cell ——Upregulation of cell adhesion molecules ——Production of cytolytic proteins ——Release of inflammatory cytokines ——Proliferation of T cells, which result in redirected lysis of CD19+ cells Dosage

• Recommended daily dose is based on patient weight • Patient weight 45 kg or more: fixed dose ——Cycle 1 ■■ Days 1-7: 9 mcg/day ■■ Days 8-28: 28 mcg/day ■■ Days 29-42: Treatment-free interval ——Subsequent cycles ■■ Days 1-28: 28 mcg/day ■■ Days 29-42: Treatment-free interval

• Patient weight less than 45 kg: dose based on body surface area (BSA) ——Cycle 1 ■■ Days 1-7: 5 mcg/m 2/day (not to exceed 9 mcg/day) ■■ Days 8-28: 15 mcg/m2/day (not to exceed 28 mcg/day) ■■ Days 29-42: Treatment-free interval ——Subsequent cycles ■■ Days 1-28: 15 mcg/m2/day (not to exceed 28 mcg/day) ■■ Days 29-42: Treatment-free interval Administration

• Hospitalization recommended for first 9 days of the first cycle and first 2 days of the second cycle • Supervision by health care professional or hospitalization for all subsequent cycle starts and re-initiation (eg, interruption of 4 or more hours) • Premedicate with dexamethasone ——Adult: 20 mg 1 hour prior to first dose of each cycle, prior to step dose (cycle 1 day 8), and when restarting infusion after interruption of 4 or more hours ——Pediatric: 5 mg/m2 to a maximum dose of 20 mg prior to first dose in first cycle, prior to step dose (cycle 1 day 8), and when restarting infusion after interruption of 4 or more hours in the first cycle • Administer as continuous IV infusion at a constant flow rate using a programmable, lockable, nonelastomeric pump with an alarm • Infuse over 24 hours or 48 hours, per physician preference considering frequency of bag changes ——10 mL/hour for 24 hours or ——5 mL/hour for 48 hours

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STAT CONSULT

• Starting volume (270 mL) is more than volume given to patient (240 mL) to account for priming of IV tubing, ensures full dose is received • Use IV tubing that contains a sterile, nonpyrogenic, low protein-binding, 0.2 micron in-line filter • Important notes ——Instructions in package insert for preparation must be strictly followed to minimize medication errors ——Do not flush infusion line or IV catheter, especially when changing infusion bags. Flushing when changing bags or at completion of infusion can result in excess dosage and complications thereof ——When administering via a multilumen venous catheter, blinatumomab should be infused through a dedicated lumen • Any unused solution in the IV bag and tubing should disposed of according to local requirements

»» If toxicity occurs at 5 mcg/m2/day or takes more than 7 days to resolve, discontinue permanently ■■ Grade 4: Discontinue blinatumomab permanently • Other clinically relevant adverse reactions ——Grade 3 ■■ Patient weight ≥45 kg: Withhold blinatumomab until no more than grade 1 (mild), then restart at 9 mcg/ day. Escalate to 28 mcg/day after 7 days if toxicity does not recur. ■■ Patient weight <45 kg: Withhold blinatumomab until no more than grade 1 (mild), then restart at 5 mcg/m2/day. Escalate to 15 mcg/m2/day after 7 days if toxicity does not recur. ■■ If toxicity takes more than 14 days to resolve, discontinue permanently ——Grade 4: Consider discontinuing blinatumomab permanently

Dose Adjustments

Specific Populations

• Treatment interruption due to an adverse event ——Interrupted for 7 or fewer days: Continue the same cycle to a total of 28 days including days before and after interruption ——Interrupted for more than 7 days: Start a new cycle • Cytokinase release syndrome (CRS) ——Grade 3 ■■ Patient weight ≥45 kg: Withhold blinatumomab until resolved, then resume at 9 mcg/day. Escalate to 28 mcg/day after 7 days if toxicity does not recur ——Patient weight <45 kg: Withhold blinatumomab until resolved, then restart at 5 mcg/m 2/day. Escalate to 15 mcg/m2/day after 7 days if toxicity does not recur ——Grade 4: Discontinue blinatumomab permanently • Neurologic toxicity ——Seizure: Discontinue blinatumomab permanently if more than 1 seizure occurs ——Grade 3 ■■ Patient weight ≥45 kg: Withhold blinatumomab until no more than grade 1 (mild) and for at least 3 days, then restart at 9 mcg/day. Escalate to 28 mcg/ day after 7 days if toxicity does not recur. »» If toxicity occurs at 9 mcg/day or takes more than 7 days to resolve, discontinue blinatumomab permanently ■■ Patient weight <45 kg: Withhold blinatumomab until no more than grade 1 (mild) and for at least 3 days, then restart at 5 mcg/m2/day. Escalate to 15 mcg/m2/day after 7 days if toxicity does not recur.

• Pregnancy ——Based on mechanism of action, blinatumomab may cause fetal harm, including B-cell lymphocytopenia, when administered to pregnant women • Nursing mothers ——Advise not to breastfeed during treatment and for at least 48 hours after last dose • Females and males of reproductive potential ——Verify pregnancy status of females prior to initiating treatment ——Advise females to use effective contraception during treatment and for at least 48 hours after last dose • Pediatric ——Safety and efficacy established in patients with relapsed or refractory B-cell precursor ALL ——Adverse reactions that occurred more frequently in pediatric patients were anemia, thrombocytopenia, vomiting, pyrexia, and hypertension • Geriatric ——No overall differences between older patients and younger patients ——Rates of neurologic toxicities, including cognitive disorder, encephalopathy, confusion, and serious infections, were higher Boxed Warnings

• Cytokine release syndrome (CRS), which may be life-threatening or fatal, occurred in patients receiving blinatumomab. ——Interrupt or discontinue treatment as recommended

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• Neurologic toxicities, which may be severe, life-threatening, or fatal, occurred in patients receiving blinatumomab ——Interrupt or discontinue treatment as recommended Contraindications

• Contraindicated in patients with known hypersensitivity to blinatumomab or any component of the product formulation Cautions

• Cytokine release syndrome ——Infusion reactions may be clinically indistinguishable from manifestations of CRS ——Serious adverse events associated with CRS included: asthenia, headache, hypotension, increased alanine aminotransferase, increased aspartate aminotransferase, increased total bilirubin, nausea, and pyrexia ——Life-threatening or fatal CRS was reported in some patients ——Closely monitor patients for signs of symptoms of adverse events. ——Management of adverse events may require temporary interruption or discontinuation of blinatumomab • Effects on ability to drive and use machines ——Because of potential for neurologic events, including seizures, patients are at risk for loss of consciousness ——Patients should be advised to avoid driving and engaging in hazardous occupations or activities such as operating heavy or potentially dangerous machinery while receiving blinatumomab • Elevated liver enzymes ——Treatment is associated with transient elevations in liver enzymes, with median time to onset 3 days. ——Grade 3 or greater elevations in liver enzyme occurred most often in the setting of CRS, but some occurred outside this setting. Median time to onset was 15 days. ——Monitor alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), and total blood bilirubin prior to start of treatment. ——Interrupt treatment if transaminases rise to more than 5 times the upper limit of normal or if bilirubin rises to more than 3 times the upper limit of normal • Immunization ——Vaccination with live virus vaccines is not recommended for at least 2 weeks prior to starting blinatumomab, during treatment, and until immune recovery after last cycle is completed.

• Infections ——Serious infections such as sepsis, pneumonia, bacteremia, opportunistic infections, and catheter-site infections may occur and can be life-threatening or fatal. ——Administer prophylactic antibiotics and employ surveillance testing during treatment, as appropriate ——Monitor for signs and symptoms of infection and treat appropriately • Leukoencephalopathy ——Cranial MRI changes showing leukoencephalopathy have been observed, especially in those with a history of prior cranial irradiation and antileukemic chemotherapy (including systemic high-dose methotrexate or intrathecal cytarabine) • Neurologic toxicities ——Most common manifestations were altered state of consciousness, dizziness, headache, and tremor, with median time to onset of 4 days ——Grade 3 or higher (severe, life-threatening, or fatal) neurologic toxicities included confusion and disorientation, convulsions, coordination and balance disorders, disturbances in consciousness, encephalopathy, and speech disorders • Neutropenia and febrile neutropenia ——Monitor laboratory parameters including, but not limited to, WBC and absolute neutrophil count during infusion ——Interrupt if prolonged neutropenia occurs • Pancreatitis ——Evaluate patients who develop signs and symptoms of pancreatitis. ——Temporary interruption or discontinuation of blinatumomab and dexamethasone may be needed • Preparation and administration errors ——Follow instructions for preparation — including admixing — and administration strictly to minimize medication errors, including underdose and overdose • Tumor lysis syndrome (TLS) ——Use appropriate prophylactic measures, including pretreatment nontoxic cytoreduction and on-treatment hydration, to prevent TLS during treatment ——Monitor for signs and symptoms ——Temporary interruption or discontinuation may be needed Adverse Effects

• Most common adverse reactions (reported in ≥20% of patients)

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STAT CONSULT

——Abdominal pain, anemia, edema, febrile neutropenia, headache, hypokalemia, nausea, neutropenia, pyrexia, thrombocytopenia Drug Interactions

• Initiation of blinatumomab treatment causes transient release of cytokines that may suppress CYP450 enzymes • Highest risk of drug-drug interaction is during first 9 days of cycle 1 and first 2 days of cycle 2 in patients receiving concomitant CYP450 substrates ——Monitor for toxicity (eg, warfarin) or drug concentrations (eg, cyclosporine) ——Adjust dose of concomitant drug as needed What to Tell Your Patient

• Blinatumomab is a prescription medicine used to treat a specific type of acute lymphoblastic leukemia (ALL) • ALL is a cancer of the blood in which a particular white blood cell is growing out of control. • Blinatumomab is administered intravenously into your vein by an infusion pump. • You will receive treatment continuously for 28 days. Then, you will receive no treatment for 14 days. This is called a cycle. • Your oncologist will decide if you should receive another cycle of treatment after each cycle. • You will stay in the hospital for the first 9 days of cycle 1 and the first 2 days of cycle 2 to check for side effects. ——Then, you may be able to go home with the infusion pump continuing to administer the medication. • Do not change the settings on your infusion pump. • Call your oncology nurse right away if you have any problems with the pump or the pump alarm sounds. • You need to keep the area around the IV catheter clean to reduce the risk of infection. You will be shown how to care for the catheter site. • Explain all your medical conditions, including ——Have you ever experienced any neurological problems, such as seizures, confusion, trouble speaking, or loss of balance? ——Do you have an infection? ——Have you ever experienced a reaction after receiving any medications through an IV? ——Have you ever received radiation treatment to the brain, or chemotherapy? ——Are you scheduled to receive a vaccine? • You should not receive a live vaccine within 2 weeks before you start treatment with blinatumomab, during

treatment, or until your immune system recovers from treatment. • Are you pregnant or do you plan to become pregnant? ——Blinatumomab may harm your unborn baby ——You should have a pregnancy test before you start treatment. ——Females who are able to become pregnant should use an effective form of birth control during treatment and for at least 48 hours after the last dose of blinatumomab. • Are you breastfeeding or do you plan to breastfeed? ——Whether blinatumomab passes into breast milk is not known ——You should not breastfeed during treatment or for at least 48 hours after your last treatment. • Blinatumomab can cause side effects that are severe, lifethreatening, or fatal. • Call your oncology nurse or doctor as soon as possible if you experience symptoms of these side effects. ——Cytokine release syndrome (CRS) or infusion reactions ■■ Chills, dizziness, face swelling, fever, headache, low blood pressure, nausea, skin rash, tiredness or weakness, vomiting, wheezing or trouble breathing ——Neurologic problems ■■ Confusion and disorientation, difficulty in speaking or slurred speech, loss of balance, loss of consciousness, seizures • Other possible side effects ——Infections: Report any signs or symptoms of an infection ——Low white blood cell counts (neutropenia): Regular blood tests will be performed to monitor your blood cell counts during treatment ——Liver function tests: Regular blood tests will be performed to monitor your liver before you start treatment and during treatment ——Inflammation of the pancreas (pancreatitis): Tell your oncology nurse or doctor right away if you experience severe stomach-area pain that does not go away, with or without nausea and vomiting • This is not a complete list of all the possible side effects you may experience. • Tell your oncology nurse or doctor if you experience any side effect, or a side effect is bothersome or gets worse. • Your oncologist may delay, temporarily stop, or completely stop your treatment with blinatumomab if you have certain side effects. ■ Prepared by Joyce Pagán

34 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

RADIATION & YOUR PATIENT

ASTRO Guidelines for Palliative RT of Bone Mets Updated Bryant Furlow Palliative radiation therapy for bone metastases is a safe and effective method for managing this painful adverse effect of advanced cancer. In an update to its guideline for evidence-based clinical palliative radiation therapy, ASTRO reports continued support for its earlier recommendations of radiation dosing schedules of 5, 6, or 10 fractions, but controversy persists for the fourth schedule: a single-fraction treatment.

ainful bone metastases can be safely and effectively treated with any 1 of 4 different radiation dosing schedules, including — controversially — a single-dose

treatment, according to updated evidence-based clinical palliative radiation therapy (RT) guideline from the American Society for Radiation Oncology (ASTRO).1 “Available literature continues to support pain relief equivalency between single and multiple fraction regimens for bone metastases,” reported lead study investigator Stephen Lutz, MD, of the department of radiation oncology, Eastern Woods Radiation Oncology in Findlay, Ohio, and coinvestigators.1 “High-quality data confirm single-fraction radiation therapy may be delivered to spine lesions with acceptable late toxicity.” The updated guideline conf irms ASTRO’s 2011 recommendations, which include 4 external-beam radiotherapy fractionation schedules for previously untreated metastatic bone tumors: • 8 Gy in a single fraction • 20 Gy in 5 fractions • 24 Gy in 6 fractions • 30 Gy in 10 fractions The findings were based on a systematic review of 20 randomized controlled trials, 32 prospective nonrandomized trials, and 4 pooled-data meta-analyses.1 The guidelines address 8 questions in all, with 100% consensus among the 8 panel members; the strength of the recommendation was “strong” for all 8 recommendations, based on a “high” strength of evidence for 5 of the 8 questions and a “moderate” strength of evidence for 3 of the questions.1 These 4 fractionation schedules represent the first question in the guidelines. “The panel’s conclusion remains that surgery, radionuclides, bisphosphonates, or kyphoplasty/vertebroplasty

do not obviate the need for external beam radiation therapy,” they noted.1 The guideline authors also noted that findings from a single prospective randomized clinical trial confirmed that retreatment of painful spinal or peripheral metastases is safe and effective.1

Which dosing schedule is best for a patient is left to the radiotherapy clinician’s acumen. CHOOSING A RADIATION THERAPY SCHEDULE

Which dosing schedule is best for a particular patient is left to the radiotherapy clinician’s acumen. “Although adherence to evidence-based medicine is critical, thorough expert radiation oncology physician judgment and discretion regarding number of fractions and advanced techniques are also essential to optimizing outcomes,” the guideline authors wrote.1 Decisions must be informed by patient comorbidities and life expectancy, tumor stage and biology, and treatment history.1 They cautioned that there remains insufficient evidence for the effectiveness of metastatic bone tumor palliation with stereotactic body radiotherapy (SBRT) and other advanced radiation therapy techniques, whether for primary palliation or re-treatment, and while these techniques “may be feasible, effective, and safe,” at this time, advanced techniques should only be used when doing so can help to build the evidence base, the panel concluded.1 “Advanced radiation therapy techniques such as stereotactic body radiation lack high-quality data, leading the

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RADIATION & YOUR PATIENT

panel to favor its use on a clinical trial or when results will be collected in a registry,” the guideline authors wrote.1 CONTROVERSIAL DOSING SCHEDULE

Patients should be advised that singlefraction radiation therapy is “associated with a higher incidence of re-treatment to the same painful site than is fractionated treatment” (20% vs 8%), the guideline authors emphasized.1 Spinal and peripheral (nonspinal) bone metastases should be re-treated with radiation therapy when they experience recurrent pain more than 1 month following external-beam radiation therapy.1

A growing evidence base favors singlefraction palliative RT for bone metastases. “A single 8 Gy fraction provides noninferior pain relief compared with a more prolonged RT course in painful spinal sites and may therefore be particularly convenient and sensible for patients with limited life expectancy,” they noted.1 However, the single-fraction schedule remains controversial. Given the scant comparative study literature on pathologic bone fracture and local metastatic bone tumor control, it remains to be seen whether single-fraction 8 Gy radiation therapy is truly equivalent to fractionated schedules, emphasized Victor J. Gonzalez, MD, and Krisha Howell, MD, of the University of Arizona Department of Radiation Oncology in Tucson, in an editorial accompanying the updated ASTRO guideline.2

“In patients with a good prognosis and risk factors for local morbidity from disease progression, fractionated RT may be justified,” they wrote.2 “In future studies, data may support the use of SFRT [single-fraction radiotherapy] in this population, but until that time, hypofractionated palliative regimens may provide a safe and effective method of improving local control beyond that provided by 8 Gy/1 [fraction].” SUPPORT FOR SINGLE-FRACTION RADIATION THERAPY

But in a commentary that also accompanied the updated ASTRO guideline, Srinivas Raman, MD, of the Odette Cancer Centre in Toronto, Ontario, Canada, and co-authors noted that a growing evidence base favors singlefraction palliative radiation therapy for bone metastases, and that this, coupled with economic studies of its relative cost-effectiveness, has led to a global push to adopt single-fraction radiation therapy for palliation of uncomplicated bone metastases.3 “Several guidelines and commentaries have highlighted the benefits of shorter treatment to both patient and society,” Dr Raman and colleagues wrote. 3 Even ASTRO’s Choosing Wisely campaign, in a similar manner, seeks to reduce the unnecessary use of radiation oncology resources, they noted.3 ASTRO’s Choosing Wisely list of practices that should not be routinely employed includes extended bone metastases radiation therapy involving more than 10 dose fractions.4 Bone metastases dose schedules once involved hundreds of fractions. A separate study of 968 patients who completed pre-radiation therapy and post-radiation therapy questionnaires, conducted by researchers in

36 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

Canada, found that patient-reported outcomes for pain, function, and symptom frustration were similar between single-fraction and multiple-fraction radiation therapy.5 But in a subset analysis of patients who had complicated bone metastases, complete pain response and functional improvement outcomes were superior in patients receiving multiplefraction radiation therapy compared with those undergoing single-fraction (19% vs 33% for complete pain response, P =.01; 69% vs 81% for functional improvement, P =.04). ■ Bryant Furlow is a medical journalist based in Albuquerque, New Mexico. REFERENCES 1. Lutz S, Balboni T, Jones J, et al. Palliative radiation therapy for bone metastases: update of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol. 2017;7(1):4-12. doi: 10.1016/j. prro.2016.08.001 2. Gonzalez VJ, Howell K. 8 Gy single-fraction radiation for bone metastases: do the data support a 1-size-fits-all approach? Pract Radiat Oncol. 2017;7(1):16-18. doi: 10.1016/j. prro.2016.08.012 3. Raman S, Chow R, Hoskin P, Chow E. How should radiation oncologists interpret the ASTRO evidence-based guideline and ASTRO Choosing Wisely campaign for the treatment of uncomplicated bone metastases? Pract Radiat Oncol. 2017;7(1):13-15. doi: 10.1016/j. prro.2016.09.008 4. Hahn C, Kavanagh B, Bhatnagar A, et al. Choosing wisely: The American Society for Radiation Oncology’s top 5 lists. Pract Radiat Oncol. 2014;4(6):349-355. 5. Conway JL, Yurkowski E, Glazier J, et al. Comparison of patient-reported outcomes with single versus multiple fraction palliative radiotherapy for bone metastasis in a population-based cohort. Radiother Oncol. 2016;119(2):202-207. doi: 10.1016/j. radonc.2016.03.025

COMMUNICATION CHALLENGES

“Could Be Worse”: When Patients Minimize Their Cancer Diagnosis

Ann J. Brady, MSN, RN-BC

The challenge is to validate the person’s feeling but to nudge him or her toward a different way of looking at things.

e have great weather in Los Angeles; just ask anyone who lives here! But even so there are ongoing debates among residents about which area in the LA Basin is hotter, which is cooler. Those who live here, even those who haven’t for very long, know what those conversations sound like: “It’s always cooler at the beach.” “The valleys are more humid.” “The west side isn’t as warm as the east side.” “As soon as you drive over the pass, the temperature jumps up 10 degrees.” Comparing one area to another seems to provide an odd comfort. I know it can get hot where I live, but I also know there are places that are worse. It’s an interesting coping mechanism. Of course, the same strategy applies in other areas of our lives. And often in interesting ways.

CASE The phone call came out of the blue. Julia and I hardly knew each other. A few years ago we were part of a group from our hospital who attended the annual Magnet conference. We’d had a few conversations, but I didn’t really know her. In fact it took me a moment to figure out who it was. “It’s Julia,” she blurted out. Then without a pause: “I had a mammogram and now they’re saying I need to have an ultrasound and probably a biopsy of my breast.” Her voice caught but then she quickly added, “They’re telling me I need to do it right away. What do you think?” I could only imagine the anxiety Julia felt. It was high enough for her to call someone she hardly knew to ask for information. More than that, she called someone she hardly knew to ask for support. That part told me something about her without her telling me in words. I tucked the thought away as we sorted through all of the possible scenarios. I reviewed what the likely next steps were but Julia kept skipping ahead, her medical knowledge a detriment to her listening. She hadn’t even had the ultrasound yet but had already thought about surgery: “I’d just as soon have a double mastectomy and not have to worry.” She imagined chemotherapy: “I can handle losing my hair.” I reminded her again and again that she was getting ahead of herself. Although doing so wasn’t unusual, it seemed to be fueling her anxiety. She admitted it was. But then she said what I have heard many patients say: “Of course it could be worse. I know that. My friend’s husband has advanced

www.OncologyNurseAdvisor.com • MAY/JUNE 2017 • ONCOLOGY NURSE ADVISOR 37

COMMUNICATION CHALLENGES

Acknowledging that what he was going through was not easy is not whining or complaining.

colon cancer. At least what they think I have isn’t as bad.” In my interactions with patients and families, it isn’t unusual to hear someone say just that: “At least I don’t have it as bad as he does.” Or “My friend’s sister had such bad nausea she nearly died from it.” I used to nod when a patient made such a remark and tried to stay noncommittal. Yet by not speaking up, I felt like I was validating what they said only because I was uncertain of how to respond. If I said something, would it undermine their coping in a negative way? The last thing I want to do is get into a debate with a patient about how to handle his or her disease. I try to respect the patient’s coping, regardless of whether I agree with it. But I also think suggesting alternate strategies, without taking away the merit of the patient’s current coping mechanism, is important. Kind of like a debate about weather: We take what is happening and make a comparison to what others have gone through. And seeing that someone else has it worse, oddly, can make us feel better, which isn’t bad. But the flip side is that this minimizes what you are going through. And minimizing the experience creates its own stress. DISCUSSION It took me a while to come up with a way to make my point about making comparisons in a way I felt was respectful and supportive. The communication challenge was to validate the person’s feeling but to nudge him or her toward a different way of looking at things. Interestingly, the idea of how to frame that came from thinking about the weather.

In Los Angeles, we don’t just compare our weather region by region; we also compare our weather to our close and famous neighbor community Palm Springs. You can be certain if the temperature in Los Angeles is 100°F and we are complaining about the heat, it will be a good 10 to 15 degrees hotter in Palm Springs. Many times during a heat wave, I have heard friends or neighbors say “Thank goodness I don’t live in Palm Springs.” But the weather in Palm Springs does not change the weather where I live. Recently a patient named Paul commented that he was grateful his disease was not as bad as someone he’d met while waiting to see his oncologist. I used my observation about the weather to make a point. “I heard it’s really hot in Palm Springs today,” I said. “Yes, well over 100, maybe 110,” Paul said. “110. Wow, that’s hot.” Then I added, “You know, when it’s hot there, it’s still hot here. It may not be as hot, but hot is hot.” I decided to do more than use an analogy. I wanted to make my point very clear. I told him I didn’t want him to minimize his experience. Acknowledging that what he was going through was not easy is not whining or complaining. It doesn’t have to be the hottest place to be plenty hot. Paul agreed that that made sense, and he would take it under advisement. Now when I see Paul, I have a short-handed way of asking how he is doing. He always laughs when I ask, “How is the weather today?” ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

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Study Shows Risk of Second Cancers Increased for Hodgkin Lymphoma Survivors Bette Weinstein Kaplan

anagement of Hodgkin lymphoma (HL) has progressed over the past 40 years, but that treatment success is bittersweet. Although survivor statistics are encouraging, a new study quantifies the risk of survivors developing second cancers. This is particularly true in people who have relatives with the disease.1 In a multi-institutional investigation utilizing the Swedish Family-Cancer Project Database, researchers studied the records of 9522 patients with primary Hodgkin lymphoma diagnosed between 1965 and 2012. They also analyzed data from 28,277 first-degree relatives of the survivors. Investigators were from the Institute of Cancer Research in London, United Kingdom, the German Cancer Research Centre in Heidelberg, and the Centre for Primary Health Care Research in Malmö, Sweden. They found that although HL survivors can now live free of the disease for many years, the increased risk of developing treatment-related complications such as second cancers and cardiovascular disease persists over a long period of time. TREATMENT MODIFICATIONS UNSUCCESSFUL

Researchers have suggested a number of factors that may contribute to these sequelae, including the patient’s age, history of smoking, site and type of

treatment, and the chemotherapy or radiotherapy dose the patient received. However, although radiotherapy and chemotherapy regimens have been modified with the goal of reducing treatment-related complications while still achieving treatment success, these changes have not reduced the risk of second cancer in HL survivors. Researchers undertook the current project, “to gain insight into the risk

The most significant factor in the risk for developing a second cancer is a family history of cancer. of second cancer after a diagnosis of Hodgkin lymphoma and its relationship to temporal changes in treatment regimens.”1 Mean age of the study participants at the time of HL diagnosis was 49 years. Median follow-up was 12.6 years, although the longest follow-up interval was extended to 48 years. Before the end of the research period, a total of 1215 second cancers occurred in 1121 patients, and 5721 patients had died. The most common second cancer was non-Hodgkin lymphoma, followed by lung cancer, breast cancer,

40 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

nonmelanoma skin cancers, leukemia, and colorectal cancer. FAMILY HISTORY OF CANCER INCREASES RISK

Researchers found that a HL survivor has a 2.4-times greater risk of developing a second cancer of any type than does a person in the general population matched for age and sex. This increased risk could remain elevated for 30 years. However, the most significant factor in the risk of developing a second cancer is whether the survivor has a family history of cancer. In this study, almost one-third of the participants who had Hodgkin lymphoma had at least 1 first-degree relative who had had cancer. If that relative had lung cancer, the survivor’s risk of developing lung cancer specifically was 3.5 times greater than that of someone who did not have a close relative with lung cancer. In a similar manner, patients with a family history of colorectal or breast cancer had double the risk of developing the same cancer. Furthermore, the number of relatives with cancer correlated with the degree of risk for the HL survivor developing a second cancer. If a patient with Hodgkin lymphoma had 2 or more first-degree relatives who had cancer, the risk of developing a second cancer more than tripled. With regard to lung cancer, the researchers demonstrated “a greater

than additive interaction” between a family history of lung cancer and treatment for Hodgkin lymphoma. They suggest that this might be the result of additional nongenetic risk factors such as smoking in the family.1 This finding is important, as it could be the reason why lung cancer still carries the highest risk, even though treatment now involves less radiation therapy. The solution to this problem may be to establish more vigorous programs to reduce smoking in patients with Hodgkin lymphoma. AGE AT DIAGNOSIS IS A FACTOR The risk of developing a second cancer was also related to the patient’s age at diagnosis — the younger the patient was at diagnosis, the greater the risk. If a woman was younger than 35 years at Hodgkin lymphoma diagnosis, she had a 14% risk of developing breast cancer, and that risk persisted for 30 years. If she was older than 35 years at diagnosis, her second cancer risk was only 3%. A NOTE OF CAUTION

The researchers concluded that since the majority of patients with Hodgkin lymphoma are cured of the disease, they no longer see an oncologist. However, since they are at increased risk for developing second cancers, the clinicians these survivors do see should monitor them for sequelae and initiate preventive treatment as necessary. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Sud A, Thomsen H, Sundquist K, Houlston RS, Hemminki K. Risk of second cancer in Hodgkin

Cancers Secondary to Hodgkin Lymphoma

NON-MELANOMA SKIN CANCERS

BREAST CANCER

LUNG CANCER NON-HODGKIN LYMPHOMA

LEUKEMIA

COLORECTAL CANCER

Advances in Hodgkin lymphoma treatment have led to significantly improved survival rates, but have also been shown to increase the risks of second cancers in survivors, particularly among those who received alkylating agents (leukemia) or underwent radiation therapy (solid tumors). A Dutch study involving more than 3000 persons with a median follow-up of 19.1 years found cumulative incidence of second cancers among survivors was 48.5% even 40 years after treatment. This study’s findings show that despite changes in cancer therapy over the years of the study (first diagnosis between 1965 and 2000), risk of second cancers was not lower among those patients treated in the later years of the study period. Therefore the researchers suggest an awareness of the increased risk is crucial in the survivorship care for Hodgkin lymphoma survivors.

lymphoma survivors and influence of family history [published online March 13, 2017]. J Clin Oncol. doi:10.1200/JCO.2016.70.9709

Reference Schaapveld M, Aleman BM, van Eggemond AM, et al. Second Cancer Risk Up to 40 Years after Hodgkin’s Lymphoma. N Engl J Med. 2015;373(26):2499-2511.

www.OncologyNurseAdvisor.com • MAY/JUNE 2017 • ONCOLOGY NURSE ADVISOR 41

FROM

hroughout the years, we have come to understand and appreciate the benefits of physical activity in maintaining a healthy lifestyle. Studies have shown this knowledge can be particularly helpful and healing to many people, especially those with breast cancer. The impact is remarkable on both mental and physical health. Many health care professionals who have worked with people with breast cancer can attest that the news is often followed by unavoidable and uncomfortable changes. It is not uncommon for emotions to shift from the initial diagnosis, throughout the course of treatment, and beyond into survivorship. The shock of being told one has breast cancer, the stress of managing treatment, and the fears of recurrence can be overwhelming. Physical changes after operative intervention or fatigue after a chemotherapy regimen, for example, can contribute to increased feelings of depression, despair, and isolation. Many patients feel a lack of control over the influence the diagnosis has taken on their minds and their bodies, leaving them feeling powerless. This article demonstrates how physical activity can improve multiple aspects of quality of life for both patients and survivors of breast cancer. MENTAL AND PHYSICAL BENEFITS Physical activity has been shown to improve mental health for people with breast cancer. For instance, both anxiety1 and depression2,3 are reduced in

Outcomes in Breast Cancer Are Improved With Physical Activity Marissa Fors, MSW, LMSW

those patients who include physical activity as part of their routine. The benefits are so remarkable that the effects are often similar to psychotherapy or pharmaceutical intervention for mild to moderate depression.3 Overwhelming anxiety or depression

can be disruptive to everyday life; finding useful ways to manage these feelings can bring relief to people who feel lost or hopeless. Whether changes in mood are influenced by the diagnosis itself or side effects from the treatments, decreased mental health can impair functioning and quality of life. Anxiety and depression may originate from fears related to the diagnosis and how it will impact patients’ plans for the future. Recurrence and dying from breast cancer are common worries that affect how patients view their lives. Studies have shown that including physical activity can reduce the risk of dying from breast cancer1,4; furthermore, physical activity can reduce the chances of disease recurrence.5 Patients can potentially improve their outcomes by incorporating fitness in their lives. Many side effects of breast cancer and its treatment options can be especially distressing and life altering. Common side effects such as pain and fatigue lower quality of life and impact day-to-day functioning. Studies have shown that these side effects could be managed with physical activity,2,3 which can be comforting to patients who struggle to diminish their impact. As health care professionals, we can empower our patients and provide the resources they need to flourish. This empowerment can lead to increased motivation for self-improvement. Physical activity has been shown to instill self-confidence in personal perception of capability and the power to gain some control over one’s body and care. 3 Patients appreciate this

Introducing and encouraging a form of physical activity can begin the process of reclaiming influence and balance in their lives. 42 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

Nurse Practitioner Associates

for Continuing Education

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FROM

encouragement to improve themselves and their lives. From moderate walking or a more vigorous jog, to taking up bicycling or swimming,4 there are a variety of activities for patients to keep active and inspired. We can encourage patients to be self-aware and appreciate that some form of activity is better than none.1 Patients can feel encouraged to know that their efforts to include physical activity, even if minimal, are beneficial. THINGS TO CONSIDER

Patients may be worried about negative side effects or the safety of physical activity while they are undergoing treatment or during recovery. This is a valid concern, as patients may want to be cautious of strenuous activities or fear adverse effects from it. Physical activity was once discouraged for certain patients with breast cancer because of concern regarding lymphedema, a potential side effect of surgery or radiation that causes swelling and pain in the arm on the affected side. Research findings have demonstrated that physical activity does not contribute to or worsen lymphedema.1

Overall, there are few negative impacts of including physical activity.3 Although physical activity is safe for both patients and survivors, patients should be mindful of their abilities and the limitations of their condition. Activities should be adjusted to patients’ ability and interest while considering their overall health and the course of disease.1 A best practice for patients is to discuss exercise safety with their physicians, understand the level of supervision required, and make the best-informed decisions for their unique needs.1

to improve many aspects of their wellbeing. They are making choices that impact their present reality and their future on the path to healing in a safe and effective way. ■ REFERENCES 1. Schmitz KH, Courneya KS, Matthews C, et al; American College of Sports Medicine. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409-1426. 2. Fisher MI, Howell D. The power of empowerment: an ICF-based model to improve self-efficacy and upper extremity function

CONCLUSION

The benefits of physical activity for people with breast cancer are vast. Researchers have found that including some form of physical activity could improve quality of life, mood, and some side effects. We can play a vital role in assisting patients to regain a sense of control in their changing landscapes. Introducing and encouraging a form of physical activity to our patients can begin the process of reclaiming some influence and balance back into their lives. When patients make healthy lifestyle choices, they are taking steps

of survivors of breast cancer. Rehabil Oncol. 2010;28(3):19-25. 3. Craft LL, Vaniterson EH, Helenowski IB, Rademaker AW, Courneya KS. Exercise effects on depressive symptoms in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev. 2012;21(1):3-19. 4. Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA. Physical activity and survival after breast cancer diagnosis. JAMA 2005;293(20):2479-2486. 5. Ibrahim EM, Al-Homaidh A. Physical activity and survival after breast cancer diagnosis: meta-analysis of published studies. Med Oncol. 2011;28(3):753-765.

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REFLECTIONS Managing Pain in a Changing Climate Tahitia Timmons, MSN, RN-BC, OCN

those experiencing breakthrough pain. Mismanagement may lead to increased episodes of discomfort and poor quality of life. The same principles used in noncancer pain should be followed in managing cancer-related pain. We should realize that the risk of addition

and tolerance do exist and discuss them with our cancer patients.4 SUBJECTIVE EXPERIENCE VS OBJECTIVE PERCEPTION

Recently, a colleague described an experience with a patient who said his pain was “horrible” and rated it a “20 out of 10.” My colleague said, “Of course, they are going to have pain. It’s normal after that type of procedure.” My colleague felt the patient had unrealistic expectations and was not prepared for what to expect. The amount of pain this patient prescribed to the procedure and my colleague’s feeling did not match. The patient’s care team was uncomfortable increasing his opioid regimen in today’s changing climate. They felt the patient’s report was abnormal, and were certain this case would show up on the survey and they would hear about it in their weekly HCAHPS meeting. After talking with my colleague, I worried about 2 things: How we contextualize normal in regard to pain, and that the HCAHPS is not meant to drive individual clinician pain-management decisions, but rather to be a tool for organizational use.5 Years ago I underwent an aortic arch replacement. My surgical team described the procedure and explained that I would have pain. Despite this, I was still surprised at the level of pain I felt the first time the medication wore off after surgery. However, the fact that they warned me allowed me to anticipate the pain — much like I can try to imagine the pain my patients suffer even though I have never experienced it. Continued on page 46

The HCAHPS is not meant to drive individual pain management decisions, but rather to be a tool for organizational use. www.OncologyNurseAdvisor.com • MAY/JUNE 2017 • ONCOLOGY NURSE ADVISOR 45

n health care, pain is an issue about which clinicians and patients are often left struggling to communicate. Clinicians can often feel frustrated by pain’s subjective nature. In the current climate of an opioid crisis and with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) focus on patient satisfaction, the discussion has arisen how best to meet what appear on the surface to be competing priorities. One of the 9 topics currently covered on the HCAHPS survey is pain management; however, changes to the survey are expected in 2018. The pain domain will remain on the survey but will no longer be a part of the value-based purchasing metric. Concerns had been raised regarding whether the increase in opioid use had coincided with pressure to ensure HCAHPS satisfaction.1 Opioid overdoses and prescribing practices have become a priority for the US Department of Health and Human Services (HHS); more than 165,000 people have died from prescription opioid overdoses since 1999.2 There is an ethical obligation for clinicians to find the best way to help patients; however, we need to be clear about the data 3: The data on the opioid crisis ref lects chronic pain not related to cancer and should not be exclusively interpreted for patients with cancer. Pain in patients with cancer needs to be carefully evaluated and all potential pathways explored, especially for patients with advanced cancers and

REFLECTIONS

My colleague was right: the patient could have been better prepared for what to expect regarding pain. Studies have shown that patients who are better prepared for what to expect regarding pain management have better outcomes.6,7,8 However, what happens when we delegitimize the patient’s pain report? My normal is not everyone’s normal. This goes back to a report by Margo McCaffery, MS, RN-BC, FAAN, an internationally recognized specialist in the nursing care of patients with pain, who said pain is “whatever the experiencing person says it is, existing whenever the experiencing person says it does.”9 When we discuss patient-centered care, pain management should be seen as the epitome of doing this. We create an additional barrier to building trust when we create competing priorities to accomplishing this. Published in 2006 yet still topical today, an article titled “Is Pain Ever ‘Nor mal’?” discussed pain and normalcy, the idea being that clinicians feel something about the validity of pain.10 We then compare our experiences with our patients’, and this colors our encounters. My colleague may have had competing priorities: the pressure of meeting the HCAHPS domain for pain management vs the clinician’s own ideas about pain. The HCAHPS domain for pain management was never meant to inf luence clinical decisions on pain management.11

multimodal methods. These methods should include both opioid and nonopioid treatments.12 In addition, the patient should be encouraged to actively engage in the process. Engaged patients have been shown to have better pain outcomes.13

Increases in drug and opioid overdose deaths — United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;16(50-51):1378-1382. 4. Bruera E, Paice JA. Cancer pain management: safe and effective use of opioids. Am Soc Clin Oncol Educ Book. 2015:e593-e599. 5. Reich DL, Porter C, Levin MA, et al. Data-driven

Patients who are better prepared for what to expect regarding pain have better outcomes.

interdisciplinary interventions to improve inpatient pain management. Am J Med Qual. 2013;28(3):187-195. 6. Adam R, Bond C, Murchie P. Educational interventions for cancer pain. A systematic review of systematic reviews with nested narrative review of randomized controlled trials. Patient Educ Couns. 2015;98(3):269-282. 7. Lemay CA, Ayers D, Franklin PD. Effective pain information pre-operatively is associated

For our patients with cancer, using the same pain scale, completing a comprehensive pain assessment at each visit, and actively listening can elicit the best response. Acknowledging that cancer pain is still underresearched and undertreated is the beginning of how we can handle pain in this changing climate. Providing cancer patients with diverse methods to become active participants in their care by educating them on what to expect can be an initial step, along with creating partnerships for managing pain through patient-centered care. ■

with improved functional gain after total joint replacement. Poster presented at: UMass Center for Clinical and Translational Science 6th Annual Research Retreat; May 20, 2016; Worcester, MA. 8. Smith MY, DuHamel KN, Egert J, Winkel G. Impact of a brief intervention on patient communication and barriers to pain management: results from a randomized controlled trial. Patient Educ Couns. 2010;81(1):79-86. 9. McCaffery M. Clinical Nursing: Nursing Practice Theories Related to Cognition, Bodily Pain, and Man-environment Interactions. Oakland, CA: Regents of the University of California, 1968. 10. Cronje RJ, Williamson OD. Is pain ever “nor-

Tahitia Timmons is the clinical oncology nurse educator for Cooper University Health in Camden, New Jersey.

mal”? Clinical J Pain. 2006;22(8):692-699. 11. Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA.

REFERENCES 1. Tefera L, Lehrman WG, Conway P.

WORK AS A TEAM Patient-centered care should be utilized when working with individual patients to complete a pain assessment. Each clinician should engage with patients individually and create a plan that best meets the patient’s needs using

3. Rudd RA, Aleshire N, Zibbell JE, Gladden RM.

Measurement of the patient experience: clarifying facts, myths, and approaches. JAMA. 2016;315(20):2167-2168. 2. Prescription opioid overdose data. Centers

2012;307(13):1377-1378. 12. Pasero C, McCaffery M, eds. Pain Assessment and Pharmacologic Management. St Louis, MO: Mosby; 2011. 13. Bernabeo E, Holmboe ES. Patients, providers, and systems need to acquire a spe-

for Disease Control and Prevention website.

cific set of competencies to achieve truly

https://www.cdc.gov/drugoverdose/data/

patient-centered care. Health Aff (Millwood).

overdose.html. Accessed May 1, 2017.

2013;32(2):250-258.

46 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com

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

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ASK A PHARMACIST

Putting a Name on the Impact of Cancer Treatment Costs I hear the term “financial toxicity” used more and more when people are discussing the cost of cancer treatments. What exactly is financial toxicity? —Name withheld upon request

As most people who work in oncology are aware, the costs of cancer treatments continue to increase, with many new treatments costing more than $10,000 a month. Patients bear an increasing proportion of this cost, typically in the form of copays, deductibles, or the Medicare “donut hole.” These increased costs affect both patients receiving oral chemotherapy and those receiving parenteral treatments.

A survey conducted in 2014 found that nearly one-quarter of insured adults younger than 65 years spent 10% or more of their household income on health care costs.1 In addition, the patient’s household finances may already be impacted by the loss of income as a result of the need for a patient or caregiver to take time off from work due to the illness or caregiving needs. For many patients with cancer, the financial toll may impact their household finances for years after they have completed their cancer treatment. Financial toxicity is one of the more common terms used to describe the impact of cancer, cancer treatments, and long-term effects on a patient’s (or their family’s) finances. Some other terms you may see include financial distress, economic burden, and financial hardship. Awareness of financial toxicity in the medical and oncology community has increased over the last several years. Some national organizations are calling for a value-based framework — the cost of the drug would be at least partially based on the magnitude of its benefit to patients — in drug approvals and pricing. Other organizations are focusing on health care reform to minimize the costs to the patient. Many organizations emphasize the need for an up-front conversation with patients about treatment costs, and to include the fi nancial impact in the

conversation when health care providers counsel patients on the adverse effects and benefits of a proposed treatment course. To facilitate these conversations, the National Comprehensive Cancer Network (NCCN) began including “evidence blocks” in their oncology treatment guidelines. These evidence blocks are designed to call attention to the affordability, efficacy, and safety of a treatment option, as well as the type and consistency of data supporting use of the regimen (eg, if multiple welldesigned trials have shown a benefit to using the regimen or if it is based on a single, small study).2 Because the problem of financial toxicity is multifaceted, there is no easy answer for how to minimize its impact on patients. Nurses play a key role in educating and advocating for their patients regarding financial and other toxicities. ■

REFERENCES 1. Financial toxicity and cancer treatment (PDQ®) – health professional version. National Cancer Institute web site. https://www.cancer.gov/ about-cancer/managing-care/financial-toxicityhp-pdq. Accessed May 2, 2017. 2. NCCN clinical practice guidelines in oncology (NCCN Guidelines®) with NCCN Evidence Blocks™. National Comprehensive Cancer Network web site. https://www.nccn.org/ evidenceblocks/default.aspx. Accessed May 2, 2017.

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

48 ONCOLOGY NURSE ADVISOR • MAY/JUNE 2017 • www.OncologyNurseAdvisor.com