Oncology Nurse Advisor Nov/Dec 2015 by Haymarket Media

ONCOLOGY NURSE ADVISOR â&#x20AC;˘ NOVEMBER/DECEMBER 2015

November/December 2015

www.OncologyNurseAdvisor.com A F O R U M F O R P H YS I C I A N A S S I S TA N T S

FEATURE

RADIATION-ASSOCIATED TOXICITIES What Will It Take for Pre-/ Rehabilitation Services to Catch On?

FEATURE

Health Literacy in Older Adults: Strategies for Integration

THE TOTAL PATIENT

Adolescent Stem Cell Donors: Benefits, Burdens, and Risks of Being a Lifeline for a Sibling

Guidelines and Genomics Improve Management of a Common Side Effect Bacteria typically present in the mouth swarming into an open wound in the ulcerative/bacteriologic phase of oral mucositis.

FROM CANCERCARE

Tips and Tools for Coping With TripleNegative Breast Cancer

ASK A PHARMACIST

Managing MS-associated Pain in Cancer Patients

VOLUME 6, NUMBER 6

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Oncology Nurse Advisor (ISSN 2154-350X), November/December 2015, Volume 6, Number 6. Published 6 times annually by Haymarket Media Inc, 114 West 26th Street, 4th 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.

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

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2015 • ONCOLOGY NURSE ADVISOR 7

CONTENTS

November/December 2015

IN THE NEWS • Communication Practices of Many US Physicians May Be Discouraging HPV Vaccination • New Therapy for TNBC Shows Promise in Laboratory Studies • Postdiagnosis Aspirin Improves Survival in Gastrointestinal Cancers … and more

NAVIGATOR NOTES Navigation Program Tackles Cancer Care on Two Fronts

Shannon Aymes, MD

FEATURES What Will It Take for These Services to Catch On? Pamela J. Haylock, PhD, RN, FAAN; Cynthia A. Cantril, MPH, RN, OCN

Health Literacy in Older Adults: Strategies for Integration Sarah Kelly, MSW, LCSW

STAT CONSULT Sonidegib (Odomzo)

RADIATION & YOUR PATIENT Oral Mucositis: The Bane of Head and Neck Radiotherapy Bryant Furlow

55 FIND US ON

Continues on page 10

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FEATURE: AYA SURVIVORS Initial Report: Ibrutinib Safe for Asymptomatic High-risk CLL

CONTENTS 43

A report on the initial findings on the safety profile of ibrutinib in asymptomatic patients with CLL, as presented at the International Workshop on Chronic Lymphocytic Leukemia.

November/December 2015

COMMUNICATION CHALLENGES They Chose You to Ask Ann J. Brady, MSN, RN-BC

Kathy Boltz, PhD

FEATURE: TECHNOLOGY IN NURSING Windows 10: Microsoft’s Apology to PC Users The software giant’s latest software package offers a mea culpa to users left on the wayside of its previous major system upgrade. Joe Dysart

THE TOTAL PATIENT Adolescent Stem Cell Donors: Benefits, Burdens, and Risks of Being a Lifeline for a Sibling

FEATURE: SURVIVORSHIP Surviving Cancer Does Not Encourage Healthier Diets in Patients

Bette Weinstein Kaplan

A recent study found that many survivors do not adhere to health dietary guidelines, and those who smoke are even less likely to follow the guidelines.

THE PATIENT’S VOICE Dedicated Discovery Cinde J. Dolphin

FROM CANCERCARE Tips and Tools for Coping With Triple-Negative Breast Cancer Victoria Puzo, LMSW

ASK A PHARMACIST MS-associated pain in cancer patients; data on cannabis Lisa A. Thompson, PharmD, BCOP

Visit ONANavigationSummit.com for these tools to help you make the most of your Summit experience. April 7-9, 2016 | Orlando, FL

Review the complete agenda and “meet” our Advisory Board, plus • Abstract Submission Guidelines for posters • Justification Toolkit • FAQs • CE Information

Bette Weinstein Kaplan

ISSUES IN CANCER SURVIVORSHIP Predicting Seizure Incidence and Frequency in Survivors of Pediatric Brain Tumors Researchers at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center sought to assess the effects of treatment for brain tumors in children over 10 years of follow-up. Bette Weinstein Kaplan

STAT CONSULT Rolapitant (Varubi) A substance P/neurokinin 1 receptor antagonist indicated for the prevention of delayed nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, in combination with other antiemetic agents.

ON THE

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10 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

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IN THE NEWS Communication Practices of Many US Physicians May Be Discouraging HPV Vaccination In a national sample, many pediatricians and primary care physicians reported communicating about HPV

vaccination with parents in ways that likely discourage them from having their children vaccinated, reported a research team led by Melissa B. Gilkey, PhD, assistant professor of population medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute in Boston, Massachusetts. Although HPV vaccination is an effective, safe, and easy way to prevent certain cancers and other conditions, very few US adolescents are vaccinated in a timely manner. Prior research has shown that a health care provider’s recommendation is the single biggest influence on whether parents decide to allow HPV vaccination of their adolescents. Gilkey and colleagues conducted a national online survey of US pediatricians and family physicians in 2014, in which they measured 5 indicators of HPV vaccine recommendation quality, including timeliness, consistency, urgency, and strength of endorsement. The study included 776 physicians; 68% were male, and 55% were in practice for 20 years or longer. The researchers found that 27% of physicians across the country reported that they do not strongly endorse HPV vaccination, and 26% and 39% reported that they do not provide timely recommendations for vaccinating girls and boys, respectively. Approximately 59% of the physicians recommended HPV vaccination more often for adolescents who they perceived to be at higher risk for getting an HPV infection, as opposed to recommending it routinely for all adolescents. Only 51% of physicians recommended same-day vaccination at the time of visit.

New Therapy for TNBC Shows Promise in Laboratory Studies Recent laboratory findings provide novel insight into potential new therapeutic approaches for triple-negative breast cancer (TNBC), a particularly difficult-to-treat and aggressive form of the disease. Scientists demonstrated in precliniCabozantinib found cal experiments that the drug caboeffective in TNBC zantinib inhibits growth of several triple-negative breast cancer subtypes. TNBC is resistant to many current therapies because it lacks the three major

receptors that are present in other forms of the disease. These proteins are targets for many common breast cancer treatments. Their absence in triple-negative disease eliminates many of the treatment options available to patients with other types of breast cancer, underscoring the importance of developing new, more targeted therapies. One target of cabozantinib is the MET protein, which drives many of the processes that make cancer aggressive and challenging to treat, including invasion of other tissues, proliferation, and survival of cancer cells. MET is overexpressed in 20% to 30% of all breast cancer cases, and is typically associated with a poor outcome. A 2009 paper demonstrated that MET is expressed in triple-negative breast cancer and is a potential therapeutic target.

12 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

Read more at https://bit.ly/1QEznMQ.

Weight-Loss Surgery Offers Dramatic Cancer Prevention Benefits In a study involving obese women most at risk for cancer, bariatric surgery slashed their weight by one-third, produced a mean weight loss of more than 100 pounds, and eliminated precancerous uterine growths. It also improved physical quality of life, improved insuAdditional benefits lin levels and glucose use, and altered of bariatric surgery the composition of gut bacteria. The study included 71 women with a mean age of 44.2 years and a mean body mass index (BMI) of 50.9, looking at the effects of bariatric surgery 1 to 3 years after surgery. A total of 68 participants underwent the procedure; two opted out of the surgery, and another died of a heart condition prior to surgery. The effects of surgery were dramatic: Mean weight loss was more than 100 pounds. Ten percent of study participants who had not had a hysterectomy showed precancerous changes in the lining of the uterus, and all of those resolved with weight loss. Read more at https://bit.ly/1jgVRF7.

Phase I Results of Targeted Treatment for Small Cell Lung Cancer Are Encouraging Remarkable early results were reported from a phase I trial of a novel agent, rovalpituzumab tesirine (Rova-T, or S16LD6.5), in 79 patients with small cell lung cancer (SCLC) who had progressed after first- or second-line therapy. SCLC is an aggressive and difficult-to-treat disease, and is frequently diagnosed after it has metastasized. Five-year survival rates are very low, at only 6%. The patients ranged in age from 44 to 81 years, with a median age of 62 years. As is standard in phase I trials, they received escalating doses of Rova-T once every 3 weeks until toxicity reached a point at which the increase in dose

needed to be stopped. The drug was designed to bind to DLL3 (delta-like protein 3), a protein highly expressed in approximately 70% of SCLCs. “Of the 48 tumor samples we were able to analyze, 33 were positive for DLL3. Among the 29 DLL3+ patients we could treat at the maximum-tolerated dose of Rova-T, 10 (34%) had a partial response and nine (31%) had disease stabilization. The duration of response among these patients was more than 178 days, with no cases of disease progression,” the researchers reported. Rova-T is an antibody drug conjugate (ADC) consisting of an antibody, a linker, and the active chemotherapy, or cytotoxic payload. The antibody portion of an ADC can recognize cell surface receptors specific to and that are overexpressed in cancer cells, allowing the delivery of the chemotherapy directly to the tumor. Read more at https://bit.ly/1PW3fTi.

Postdiagnosis Aspirin Improves Survival in Gastrointestinal Cancers Aspirin improves survival in patients with tumors situated throughout the gastrointestinal (GI) tract, results from a large study in The Netherlands show. This is the first time that survival data from patients with tumors in different GI locations have been analyzed at the Wonder drug aids in same time. The results of the study, GI cancer survival involving nearly 14,000 patients, may lead to new insights regarding the use of aspirin in GI cancer. The research team analyzed data from 13,715 patients with a GI cancer diagnosed between 1998 and 2011. By linking the data to drug dispensing information from PHARMO, the team was able to show an association between aspirin use after a cancer diagnosis and overall survival. Patients using aspirin after their diagnosis had a chance of survival twice as high as that of those who did not use it in the same circumstances. Read more at https://bit.ly/1lFJQv1.

For full news stories visit OncologyNurseAdvisor.com

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2015 • ONCOLOGY NURSE ADVISOR 13

The researchers plan to continue exploring the potential of MET inhibitors as therapies for TNBC in addition to conducting further analysis on their models to define characteristics that may be used as diagnostic tools.

NAVIGATOR NOTES

ay-navigators are being used to break communication boundaries and ease the burden of health care coordination for patients with cancer. A novel program offers the services of a lay-navigator in the form of senior-year university students participating in a 2-year fellowship. “A lay navigator program is a huge advantage for patients that might be so overwhelmed with the gravity of their illness as well as the complexity of the multiple clinic appointments and physicians they are scheduled to see. Having a support system is not only helpful for the patient, but also for their care team as well,” Brandi R. Page, MD, assistant professor Radiation Oncology and Molecular Sciences at Johns Hopkins School of Medicine, explained to Oncology Nurse Advisor (written communication, September 2015). Some patients have a difficult time with the situation, and they may forget to ask questions. A lay-navigator can facilitate getting the most out of each doctors’ appointment. “In terms of the health care system, lay-navigators are a huge benefit to helping make sure patients are also getting the most out of their visit as well,” Page said. Navigating through our complex and often fragmented health care system can be challenging. A lay-navigation system aims to help the patient and family members coordinate care, provide education, access community resources, and navigate the health care system with a one-on-one relationship whilst providing psychosocial and logistical support.1

Navigation Program Tackles Cancer Care on Two Fronts Shannon Aymes, MD

One such prog ra m a i med at providing lay-navigator support (referring to them as strategists) for cancer patients is the TaketheFight organization. Strategists with TaketheFight are undergraduate students or recent graduates who focus on

supporting the patient and their care team with the goal of improved adherence to care.2 The strategists commit to 2 years of service in addition to onsite training at the organization’s Summer Oncology Academy of Excellence (SO-AX). TaketheFight pays for travel plus 2 meals per day for strategist candidates, who must attend the entire training event in person. In the first year of service, strategists function as lay-navigators, attending doctor’s appointments and treatments with their patients. Strategists have access to their patients’ medical records, as allowed by HIPAA regulations.2 Strategists are in their final year of college during their service year, which is an unpaid fellowship year. The second year involves the strategist identifying a problem they experienced as a lay-navigator, such as educational barriers, disparities in clinical trial enrollment, and nonadherence, and they focus on ways to correct the problem.2 In this second year, strategists are fulltime employees of TaketheFight at its headquarters in New York City. “The patients benefit through receiving an extra pair of eyes who are dedicated to just them, and their needs as a patient. Our strategists become caring, passionate lay-navigators for their patients. We strategize to make appointments more efficient in order to maximize the time spent with physicians. We can help ensure that all of the patient’s concerns and questions are brought to the doctor. We support patients to execute the doctor’s treatment strategy more efficiently, and we facilitate the exchange

The second year involves the strategist identifying a problem they experienced and focus on ways to correct the problem. 18 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

of medical information to increase patient understanding. Additionally, we act as a layer of support, providing patients confidence and stability in what can be a very destabilizing environ-

“We act as a layer of support, providing patients confidence and stability.” ment,” noted Hannah Montague, a student at Wake Forest University and TaketheFight strategist (personal communication, September 2015). In a study looking at the use of lay-navigators in medically underserved patients, researchers found that the lay-navigators facilitated communication, helping the patients be more comfortable with talking about their health and feelings.1

Furthermore, they found that laynavigators helped providers keep track of their patient’s status and maintain the ability to reach patients who otherwise may have been lost to follow-up.1 Limitations of lay-navigators noted in this study included learning to set boundaries and handling the emotional aspects of their roles, in which the author pointed out nurses and other team members stepped in to help in these situations.1 Montague echoes that statement. “It’s emotionally challenging. Being a strategist forces you to confront at an early age, some of the hardships of life. It’s a privilege and an honor to stand with someone when they are battling this disease. It changes your perspective on life.” “A lthough we don’t yet have def initive data regarding survival statistics with patients that do and don’t have a TaketheFight strategist, there is definitely known improvement in quality of life and survival amongst

patients that have stronger social support systems in place. I’ve personally seen patients have more peace of mind with a support system along for their journey, as well as someone who can truly facilitate the patient’s navigation through a system that can be somewhat scary sometimes,” Page explained to Oncology Nurse Advisor. “Some patients have a built-in support system (spouse, adult child, best friend, sibling) that fulfills this function, but even for patients that have a fantastic support system at home, a lay-navigator can be a huge help to them.” ■ Shannon Aymes is a medical writer based in Apex, North Carolina. REFERENCES 1. Meade CD, Wells KJ, Arevalo M, et al. Lay navigator model for impacting cancer health disparities. J Cancer Educ. 2014;29(3):449-457. 2. TaketheFight Web site. http://takethefight. org. Accessed November 30, 2015.

This activity is jointly provided by Global Education Group and Haymarket. Target Audience The educational design of this activity addresses the needs of oncology nurse navigators involved in the treatment of patients with cancer.

Effectively Navigate Your Patients Through The Oncology Care Continuum April 7 - 9, 2016 Gaylord Palms, Orlando, FL View the complete agenda, expert faculty, and registration information at www.ONANavigationSummit.com Register and use code “ONAHPA3” to save $30. Note: Offer expires 2/29/16; discount offers may not be combined nor may they be retroactively applied.

Statement of Need/Program Overview Because navigators explore all aspects of patient needs, they need to understand all issues involved and can be only as successful as the information and knowledge they have. Thus, we continue to offer an educational conference with the purpose of bringing together oncology nurse navigators and providing them with the opportunity to receive education that addresses their learning needs, builds their confidence, and increases their professional competency, thus allowing them to provide optimal patient care. Nursing Continuing Education Global Education Group is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s COA. This educational activity for 14.5 contact hours is provided by Global Education Group. Nurses should claim only the credit commensurate with the extent of their participation in the activity. For information about the accreditation of this program, please contact Global at 303-395-1782 or inquire @globaleducationgroup.com.

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2015 • ONCOLOGY NURSE ADVISOR 19

FEATURE | Prehabilitation/rehabilitation Services

What Will It Take for These Services to Catch On? Two of our ONA Navigation Summit advisors discuss the emerging role of prehabilitation and rehabilitation in the continuum of cancer care. PAMELA J. HAYLOCK, PhD, RN, FAAN; CYNTHIA A. CANTRIL, MPH, RN, OCN

n a recent letter to the editor, oncology rehabilitation nurse navigator, Mattthew LeBlanc, writes: “… oncology nurses need to get serious about cancer rehabilitation.”1 The Oncology Nursing Society (ONS) was first to offer a practical definition of cancer rehabilitation, when Past Presidents Linda O’Connor and Deborah Mayer composed the comprehensive ONS Position Statement approved by the ONS Board of Directors in 1989—that was 26 years ago.2 ONS no longer publishes its own rehabilitation position, but endorsed the position of the Association of Rehabilitation Nurses (ARN), last revised in 2012.3 In 1992, Mayer was guest editor for a Seminars in Oncology Nursing issue focused on rehabilitation as an integrated conceptual approach to the patient with cancer. In her introduction, Mayer notes policy and funding-related obstacles to implementation of this integrated conceptual approach, and calls for oncology nurses to work individually and collectively to change this.4 Expanding evidence tells us that 65% to 90% of cancer survivors could benefit from prehabilitation and/or rehabilitation services.5,6 Yet, despite calls to action and the passage of nearly 30 years’ time since publication of the ONS Position advocating routine integration of rehabilitation in cancer care, rehabilitation—let alone prehabilitation services—continue to be vastly underused.5 The ONS 2014-2018 research agenda priority topics for research include symptoms, late

22 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

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FEATURE | Prehabilitation/rehabilitation services effects and survivorship care, palliative and end-of-life care, self-management, aging, family and caregivers, improving health care systems, and risk reduction.7 Although each of these topics could or should include prehabilitation and rehabilitation assessments and interventions (at least in the Executive Summary), the words prehabilitation and rehabilitation are missing. LeBlanc notes, “Rehabilitation is part of standard care for many medical issues, such as stroke, heart attack, traumatic brain injury, and orthopedic surgeries. To have one of these diagnoses and not get rehabilitation would be considered substandard care. Our patients deserve rehabilitation as well, and to not get it should be considered substandard care.”1 EMBRACING THESE SERVICES

What’s the problem? Why do oncology nurses have yet to embrace rehabilitation and prehabilitation as necessary elements of cancer care? A reason rehabilitation, and more recently, prehabilitation, services are underused could be the general lack of knowledge in professional and public sectors about what these services offer in cancer care. Unlike the obvious roles of medical and radiation oncologists, diagnostic radiologists, surgeons, and pathologists, it is far from clear where physiatrists fit. In addition, many health care professionals do not even know the term physiatrist, who physiatrists are, and what this specialty

LeBlanc notes: “... Our patients deserve rehabilitation as well, and to not get it should be considered substandard care.” offers. The medical specialty now recognized as physical medicine and rehabilitation (PM&R) emerged from identified physicians specializing in physical medicine.8 The emergence of PM&R as a specialty practice was driven by needs to restore injured soldiers’ capabilities as they returned from WWII, and the polio epidemic of the early 1950s.8 Physiatric practices focus on children and adults, and cross diagnostic groups and practice settings. The lack of focus on one organ or system presents challenges in explaining the field to colleagues, policymakers, and the public. Close ties with physical therapy and physical therapists remain, contributing to minimal public and professional awareness of PM&R as a recognized medical specialty.9 Elizabeth

Sandel, past president of the American Association of Physical Medicine and Rehabilitation (AAPM&R), describes PM&R as “incomprehensively diverse, lacking focus, and misunderstood,” and suggests this is the “result of the field’s integration of primary and specialty aspects of practice, its expanding scope of practice, the relatively small number of practicing physiatrists, and an inadequate representation in many geographic areas across the world.”9 NAVIGATION THAT FACILITATES ACCESS Prehabilitation Cancer prehabiltitation is “a process on the

cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identifies impairments, and provides targeted interventions that improve a patient’s health to reduce the incidence and severity of current and future impairments.”6 Improvements in physical and psychological health outcomes among survivors, decreases in treatment-related morbidity, and increased cancer treatment options are increasingly associated with patients’ access to and use of prehabilitation and rehabilitation services.6,10,11 Nurse navigators often meet patients as diagnostic and treatment planning processes begin, and as such, are positioned to facilitate integration of these services with cancer care. Further, the period of time immediately after cancer diagnosis appears to be a teachable moment—a time when patients may be more receptive to and likely to adhere to health behavior changes learned during prehabilitation.12 Multimodal prehabilitation interventions demonstrate utility among patients awaiting surgery, and its evidence of efficacy in downstaging solid tumors, thereby increasing treatment options, and decreasing hospital length of stay.6,13 Table 1 identifies useful multimodal prehabilitation interventions associated with four common cancer diagnoses. Rehabilitation ONS defined cancer rehabilitation in 1989 as “a process by which individuals within their environments, are assisted to achieve optimal functioning within the limits imposed by cancer.”2 After diagnosis and staging, physiatrists consider the impact of diagnosis and prognosis on patients’ function and quality of life, as defined by day-to-day activities, painful conditions, and symptoms that affect health and well-being. Physiatrists evaluate patients and design treatment plans, taking into account bio-psycho-social and ecological factors affecting function and quality of life.9 SUMMARY In 1992, Pamela Watson, ScD, RN, then professor in the Department of Rehabilitation Medicine, Jefferson Medical

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FEATURE | Prehabilitation/rehabilitation services TABLE 1. Multimodal Prehabilitation Interventions Breast Cancer Nutrition Psychosocial support and stress reduction Shoulder and cervical ROM Smoking cessation Total body strengthening Upper body strengthening exercises Head and Neck Cancer Balance exercises Cervical ROM Smoking cessation Stress reduction strategies Swallowing exercises Lung Cancer Balance exercises Breathing exercises Cardiovascular exercises Smoking cessation Total body strengthening Prostate Cancer Balance exercises Nutrition Pelvic floor exercises Psychosocial support and stress reduction Smoking cessation Key: ROM, range of motion.

suggests, are we ready, willing, and able to meet, learn from, and collaborate with the rehabilitation professionals in our organizations to help “cancer patients suffer less?”1 ■ Pamela Haylock is a cancer care consultant and educator based in Medina, Texas. Cynthia Cantril is director Oncology Service Lines/ Patient Navigation, Cancer Support Services at Sutter Health, Santa Rosa, California. REFERENCES 1. LeBlanc MR. Oncology nurses need to get serious about cancer rehabilitation. Clin J Oncol Nurs. 2015;19(5):500. 2. Mayer D, O’Connor L. Rehabilitation of persons with cancer: an ONS position statement. Oncol Nurs Forum. 1989;16(3):433. 3. Association of Rehabilitation Nurses. Rehabilitation of people with cancer. Oncology Nursing Society (ONS) web site. https://www.ons.org/advocacypolicy/positions/practice/rehabilitation. Accessed November 16, 2015. 4. Mayer DK. Introduction. Sem in Oncol Nurs. 1992;8(3):163. 5. Cheville AL, Beck LA, Petersen TL, Marks RS, Gamble GL. The detection and treatment of cancer-related functional problems in an outpatient setting. Supportive Care in Cancer. 2009;17(1):61-67. 6. Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil. 2013;92(8):715-727. 7. Knobf MT. Oncology Nursing Society 2014−2018 Research Agenda.

College, contributed an overview of cancer rehabilitation. Watson wrote, “Cancer care cannot be complete if only the disease is treated without attention to the remaining indispensable dimension of rehabilitation.”14 Some progress in establishing rehabilitation as a component of cancer care is evident in 2015. Also evident in 2015, oncology nurses in all settings—particularly oncology nurse navigators— could be substantially more engaged in efforts to confirm rehabilitation and prehabilitation as essential elements of quality cancer care. Susan J. Mellette, MD, professor Medical Oncology and Rehabilitation Medicine, and Gwendolyn G. Parker, RN, MS, OCN, clinical nurse specialist, both at Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia, introduce the caveat in rehabilitation’s future directions: “The keystone for the future of cancer rehabilitation is widespread recognition of the importance of providing creative and well-researched rehabilitation measures ...”15 Mellette and Parker also state, “The nursing profession has often led the way in emphasizing quality of life issues and can be expected to continue to do so in fostering appropriate physical, psychosocial, and vocational rehabilitation for all cancer patients.”15 Have we lost our way? Or, as LeBlanc

Oncology Nursing Society (ONS) web site. https://www.ons.org/ sites/default/files/2014-2018%20ONS%20Research%20Agenda%20 Executive%20Summary.pdf. Accessed November 16, 2015. 8. AAPMR History Preservation Committee. The history of the specialty of physical medicine and rehabilitation. American Academy of Physical Medicine and Rehabilitation (AAPM&R) web site. http://me.aapmr.org/kn/article.html?id=67. 9. Sandel ME. The philosophical foundations of physical medicine and rehabilitation. American Academy of Physical Medicine and Rehabilitation (AAPM&R) web site. http://me.aapmr.org/kn/article.html?id=68#. 10. Hanssens S, Luyten R, Watthy C, et al. Evaluation of a comprehensive rehabilitation program for post-treatment patients with cancer. Oncol Nurs Forum. 2011;38(6):E418-E424. 11. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. CA Cancer J Clin. 2013;63(5):295-317. 12. Karvinen K, Bruner B, Truant T. The teachable moment after cancer diagnosis: perceptions from oncology nurses. Oncol Nurs Forum. 2015;42(6):602-609. 13. Silver JK. Cancer prehabilitation and its role in improving health outcomes and reducing health care costs. Semin Oncol Nurs. 2015;31(1):13-30. 14. Watson PG. Cancer rehabilitation: an overview. Semin Oncol Nurs. 1992;8(3):167-173. 15. Mellette SJ, Parker GG. Future directions in cancer rehabilitation. Semin Oncol Nurs. 1992;8(3):219-223.

26 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

FEATURE | Health Literacy in Older Adults

Health Literacy in Older Adults: Strategies for Integration Age-related decline complicates patients’ ability to understand their care. These key points can help improve the health literacy of older patients. SARAH KELLY, MSW, LCSW

ealth literacy is an issue facing many patients who receive a cancer diagnosis, as well as their caregivers. The National Assessment of Adult Literacy determined that only 12% of adults were proficient in health literacy skills.1 Of this group, only 3% of older adults were assessed as health literate.1 For older adults, health literacy levels, which directly impact health outcomes, are well below proficient. Low health literacy is directly tied to poor health outcomes and is associated with higher hospitalization rates, difficulty managing comorbid diseases, psychological distress, and increased mortality.2 Through increasing awareness and understanding of health literacy, health professionals are in a unique position to assist older adult patients with this important aspect of consumer-centric care. WHAT IS HEALTH LITERACY? Health literacy is defined as the degree to which a person has the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.3 Health literacy is contingent on both the patient and the multiple systems the patient is navigating. The oncology world—including medical facilities, home care services, and social services—is its own system, with its own language and communication style. Patients are an integral part of this system, and inviting them to become an active participant in their care is important. Continues on page 28

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2015 • ONCOLOGY NURSE ADVISOR 27

FEATURE | Health Literacy in Older Adults HOW CAN WE HELP? The most recent and exciting development in this area was the Cancer Health Literacy Study by the Virginia Commonwealth University Massey Cancer Center in which researchers worked to create a valid and reliable assessment tool specific to health literacy and cancer patients. You can learn more about the study here: https://www.massey.vcu. edu/news/blog/2014/massey-researchers-develop-the-firstcancer-health-literacy-tool/.

Some helpful tools are a glossary of medical terms, a personal health journal, and a personal health record. Establish a supportive environment Establishing an environment that is patient-centered and supportive is integral in laying the groundwork for effective learning.4 Stress and anxiety can limit the ability to listen, learn, and retain information, especially for the older adult. As health professionals, we want to communicate respect, acceptance, and self-determination. With these core values in mind, we have the ability to successfully engage and work with clients to assess and achieve learning goals. Know your learner Who is the patient you are working with? Not every older adult is the same.5 The older adult patient is coming in with a wealth of life experience, as well as their own individual life view. Through interviewing techniques geared toward assessing the older adult patient’s health literacy capacity and ability, we can evaluate the patient’s needs, as well as skill areas, to establish the patient’s learning style. What helps the patient learn? • Audio • Video • Literature • Images/graphics The patient’s knowledge and skill set can be applied to new medical information through assessment and psychoeducation. Discuss patient-centered care An open, honest conversation with the older adult patient about patient-centered care and how health care has evolved is an important part of care. Access to medical information through technology has expanded, providing patients with myriad resources that while helpful, may be confusing.6 In addition, older adult

patients may be more reticent to challenge their doctor’s opinions or even ask appropriate questions for clarification about health issues. With all of this in mind, they may refrain from asking key questions about their care, or feel confused about where to access important health information. As health professionals, we can encourage and assist them to become self-advocates in this capacity. Also important, the interdisciplinary team should to work together to discuss the older adult patient’s specific needs regarding health literacy to assist them with this process. Use plain language Plain language is communication that users can understand the first time they read or hear it. Key elements of plain language include: • Organizing information so that the most important points come first, • Breaking complex information into understandable chunks, • Using simple language and defining technical terms.7 Assess, acknowledge, and utilize strengths The older adult patient has numerous strengths that can assist them in improving health literacy. An important aspect of care is to work with older adults to assess strengths and provide feedback regarding strengths and self-care. Foster independence Maintaining independence is an incredibly important part of aging. Aging brings many

Resources for clinicians • Health literacy action: Toolkit for patient educators (Cancer Patient Education Network) www.cancerpatienteducation.org/health-literacy.shtml • American Cancer Society www.cancer.gov • Improving Health Literacy for Older Adults (Centers for Disease Control and Prevention) www.cdc.gov/healthliteracy/pdf/olderadults.pdf • NIHSeniorHealth http://nihseniorhealth.gov/ • Improving Health Literacy: Training Resources: Welcome (University of Michigan Library) http://guides.lib.umich.edu/c. php?g=283033&p=1885789 • Doctor-Patient Communication (CancerCare) www.cancercare.org/tagged/ doctor-patient_communication

28 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

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FEATURE | Health Literacy in Older Adults changes that can include loss of independence due to physical, cognitive, and social changes. Provide appropriate tools and resources to older adult patients, and allow them to use these to manage their care.

US Department of Health and Human Services; 2011. AHRQ Publication No. 11-E006. http://www.ncbi.nlm.nih.gov/books/NBK82434/. Accessed November 30, 2015. 3. US Department of Health and Human Services. Health communication. In: US Department of Health and Human Services. Healthy People 2010.

WHAT TOOLS ARE AVAILABLE?

Washington, DC: US Government Printing Office; 2000. http://www.

Numerous tools are available to assist patients with improving health literacy. Some helpful tools are a glossary of medical terms; a personal health journal that includes a medication list, symptoms log, section to write questions and concerns to discuss with health care provider, and important numbers related to their care; and creating a personal health record (PHR) that keeps medical information in one place. ■

healthypeople.gov/2010/Document/HTML/Volume1/11HealthCom.htm. Accessed November 30, 2015. 4. Cornett S. The effects of aging on health literacy. http://medicine.osu. edu/sitetool/sites/pdfs/ahecpublic/HL_Module_Elderly.pdf. Accessed November 30, 2015. 5. American Psychiatric Association. What mental health providers should know about working with older adults. American Psychological Association Web site. http://www.apa.org/pi/aging/resources/guides/ practitioners-should-know.aspx. Accessed November 30, 2015.

Sarah Kelly is an oncology social worker and coordinator for Older Adult Services at CancerCare.

6. Centers for Disease Control and Prevention, US Department of Health and Human Services. Improving Health Literacy of Older Adults: Expert Panel Report 2009. Atlanta, GA: US Department of Health and Human Services;

REFERENCES 1. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy.

2009. http://www.cdc.gov/healthliteracy/pdf/olderadults.pdf. Accessed November 30, 2015. 7. Office of Disease Prevention, US Department of Health and Human

Washington, DC: US Department of Education, National Center for

Services. Plain Language: A Promising Strategy for Clearly Communicating

Education Statistics; 2006. NCES 2006-483.

Health Information and Improving Health Literacy. Rockville, MD: US

2. US Department of Health and Human Services. Health Literacy

Department of Health and Human Services. http://www.health.gov/

Interventions and Outcomes: An Updated Systematic Review [structured

communication/literacy/plainlanguage/IssueBrief.pdf. Accessed

abstract]. Rockville, MD: Agency for Healthcare Research and Quality,

November 30, 2015.

Do you have a story you want to share? Oncology Nurse Advisor welcomes narrative essays from oncology nurses for Reflections, our narrative medicine blog. Write 800 to 1,200 words about a patient or life experience that was meaningful to you or a perspective on oncology patient care, and email the manuscript to editor.ona@haymarketmedia.com.

30 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

STAT CONSULT Sonidegib (Odomzo) Drug Type

• Hedgehog pathway inhibitor Indications

• Treatment of adult patients with locally advanced basal cell carcinoma that has recurred following surgery or radiation therapy, or those who are not candidates for surgery or radiation therapy

Mechanisms of Action

• Inhibits the Hedgehog pathway • Binds to and inhibits Smoothened, a transmembrane protein involved in Hedgehog signal transduction Dosage and Administration

• 200 mg orally once daily until disease progression or unacceptable toxicity • Take on an empty stomach, at least 1 hour before or 2 hours after a meal • If a dose is missed, resume dosing with the next scheduled dose Dosage Adjustments

• Interrupt sonidegib for ——Severe or intolerable musculoskeletal adverse reactions ■■ First occurrence of serum CK elevation between 2.5-10× ULN ■■ Recurrent serum CK elevation between 2.5-5× ULN • Resume sonidegib at 100 mg daily upon resolution of clinical signs and symptoms • Discontinue sonidegib permanently for ——Serum CK elevation >2.5× ULN with worsening renal function ——Serum CK elevation >10× ULN ——Recurrent CK elevation >5× ULN ——Recurrent severe or intolerable musculoskeletal adverse reactions Specific Populations

• Pregnancy

——Can cause fetal harm when administered to a pregnant woman based on its mechanism of action • Nursing mothers ——Do not breastfeed during treatment with sonidegib and for at least 20 months after the last dose • Pediatric ——Not established • Geriatric ——No overall differences in safety between older and younger patients • Renal impairment ——No dose adjustment is recommended for patients with renal impairment • Hepatic impairment ——No dose adjustment is recommended for patients with mild hepatic impairment ——Sonidegib has not been studied in patients with moderate or severe hepatic impairment Boxed Warnings

• Sonidegib can cause embryo-fetal death or severe birth defects when administered to a pregnant woman, and is embryotoxic, fetotoxic, and teratogenic in animals • Verify pregnancy status of females of reproductive potential prior to initiating therapy • Advise females of reproductive potential to use effective contraception during treatment and for at least 20 months after the last dose • Advise males of potential risk of exposure through semen and to use condoms with a pregnant partner or a female partner of reproductive potential during treatment and for at least 8 months after last dose

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STAT CONSULT Cautions

• Advise patients not to donate blood or blood products during treatment with sonidegib and for at least 20 months after the last dose • Obtain serum CPK and creatinine levels prior to initiating therapy, periodically during treatment, and as clinically indicated • Temporary dose interruption or discontinuation of sonidegib may be required based on the severity of musculoskeletal adverse reactions Adverse Effects

• Most common adverse reactions (≥10%) ——Abdominal pain, alopecia, decreased appetite, diarrhea, dysgeusia, fatigue, headache, muscle spasms, musculoskeletal pain, myalgia, nausea, pain, pruritus, vomiting, weight loss Drug Interactions

• Coadministration with CYP3A4 inducers ——Avoid strong and moderate CYP3A4 inducers (eg, carbamazepine, efavirenz, phenytoin, rifampin, tricyclic antidepressants) • Coadministration with CYP3A4 inhibitors ——Avoid strong CYP3A4 inhibitors (eg, itraconazole, ketoconazole, nefazodone, posaconazole, voriconazole) ——Avoid long-term (>14 days) use of moderate CYP3A4 inhibitors (eg, atazanavir, diltiazem, fluconazole) ■■ If coadministration cannot be avoided, monitor closely for adverse reactions, particularly musculoskeletal adverse reactions What to Tell Your Patient

• Sonidegib is a prescription medicine used to treat adults with basal cell carcinoma that has come back following surgery or radiation or that cannot be treated with surgery or radiation • Tell your health care provider if you ——Have muscle pain or spasms or have a history of a muscle disorder called rhabdomyolysis or myopathy ——Have any other medical conditions ——Are pregnant or plan to become pregnant ——Are breastfeeding or plan to breastfeed • Take sonidegib exactly as your health care provider tells you • Take 1 time each day, at least 1 hour before or 2 hours after a meal • If you miss a dose, skip the missed dose, and take the next dose as scheduled

• Sonidegib should be stored at room temperature • Avoid donating blood or blood products during treatment and for 20 months after your final dose • Muscle spasms and muscle pain are common with sonidegib, but can also sometimes be symptoms of serious muscle problems ——Sonidegib can increase your risk of muscle pain and, rarely, a serious condition caused by injury to the muscles that can lead to kidney damage ——Tell your health care provider right away if you develop any new or worsening muscle spasms, pain or tenderness, dark urine, or decreased amount of urine during treatment ——Your health care provider should do a blood test to check for muscle problems and to check your kidney function before you start taking sonidegib, during treatment, and if you develop muscle problems • The most common side effects of sonidegib include ——Abdominal pain, change in taste, decreased appetite, diarrhea, hair loss, headache, itching, nausea, tiredness, vomiting, weight loss • Special instructions for female patients ——Sonidegib can cause absence of menstrual periods in females who are able to become pregnant ■■ Not known whether this effect is permanent ■■ Talk to your health care providers about fertility concerns ——Your health care provider will do a pregnancy test before you start taking sonidegib ——You should avoid becoming pregnant during treatment and for at least 20 months after your final dose ——Talk to your health care provider ■■ About what birth control method is right for you during this time ■■ If you have unprotected sex or if you think your birth control has failed ■■ If you become pregnant or think you may be pregnant • Special instructions for male patients ——Do not donate semen while you are taking sonidegib and for at least 8 months after your final dose ——You should always use a condom during sex with female partners who are pregnant or who are able to become pregnant while you are receiving treatment and for at least 8 months after your final dose ——Tell your health care provider right away if your partner becomes pregnant or thinks she is pregnant while you are taking sonidegib Prepared by Jason Hoffman, PharmD, RPh.

32 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

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RADIATION & YOUR PATIENT

Oral mucositis in the ulcerative/ bacteriologic phase

Oral Mucositis: The Bane of Head and Neck Radiotherapy Bryant Furlow Managing radiation-associated oral toxicities remains challenging, but evidencebased clinical practice guidelines are now available for oral mucositis, and the field is on the cusp of genomics-based patient risk stratification, says an expert in the field.

adiation therapy of the head and neck frequently causes acute and late oral toxicities, including mucositis, trismus due to f ibrosis, impaired or lost saliva production (xerostomia), and xerostomia-related radiation dental caries (cavities).1-6 Oral mucositis is a particularly common and painful side effect of radiotherapy and chemoradiation for head and neck

cancer; it can lead to malnutrition, infection, and disruptions in cancer treatment.1-6 Oral mucositis is also increasingly common among patients with breast cancer, who are treated with conventional chemotherapy and newer targeted therapies.7 “Patients receiving radiation therapy for head and neck cancer almost always develop radiation-induced oral mucositis,” notes Rajesh V. Lalla, DDS, PhD, associate professor of Oral Medicine at the University of Connecticut Health Center in Farmington, Connecticut, a leading researcher on the treatment of mucositis. “These lesions are very painful and can have significant negative impact on patients’ ability to maintain a normal diet. Patients often need to be fed via a stomach tube and receive strong opioid pain medications.” In some cases, oral symptoms are so severe that radiotherapy must be interrupted or discontinued, which can affect the success of a cancer treatment plan, Lalla tells Oncology Nurse Advisor. “Any patient for whom the radiation field includes oral mucosa is at risk,” agrees another authority in the field, Stephen Sonis, DMD, DMSc, professor of Oral Medicine at Harvard School of Dental Medicine and senior surgeon at Brigham and Women’s Hospital and the Dana-Farber Cancer Institute, in Boston, Massachusetts. “Cumulative doses of radiation greater than 30 Gy almost always produce ulceration [of the oral mucosa]. Thus, patients being treated with standard chemoradiation regimens for cancers of the mouth and oropharynx are at high risk for oral mucositis, and 70% or more develop severe oral mucositis.” Patients treated with similar regimens for hypopharyngeal or laryngeal cancers are at slightly lower risk of oral mucositis—approximately 60%, Sonis

says—but face higher risk of developing hypopharyngeal lesions. Unlike xerostomia, which can be permanent in patients who undergo radiotherapy or chemoradiation of the head and neck, oral mucositis usually resolves once radiotherapy ends. “While the time to spontaneous resolution of oral mucositis may vary among [patients] from about 2 to 6 weeks following the last day of radiation, it is very unusual for chronic lesions to persist,” Sonis explains. TREATMENT OPTIONS Despite the high incidence of oral mucositis, impact on patients’ quality of life and treatment plan implementation, and economic costs, there are few treatment options. “Palifermin (Kepivance) is approved for use in preventing severe oral mucositis in patients receiving conditioning regimens prior to stem cell transplant for hematologic malignancies,” notes Sonis.

Preradiation dental evaluation and treatment is mandatory. A number of palliative agents, approved as devices, are available to help mitigate mucositis pain including GelClair, Episil, and MuGard.8 Management of oral mucositis includes general supportive care, pain management, and infection prevention and treatment. Lalla was lead author of evidence-based clinical practice guidelines for oral mucositis that were promulgated by the Multinational Association of Supportive Care in

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RADIATION & YOUR PATIENT TABLE 1. Radiotherapy-related female sexual issues Level

Definition

One or more systematic review(s), meta-analysis of all published RCTs; evidence-based clinical practice guidelines

One or more well-designed RCT(s)

III

Nonrandomized controlled trial(s)

Case-control, cohort studies

Key: RCTs, randomized controlled trials.

Cancer (MASCC), in affiliation with the International Society of Oral Oncology (ISOO).3 A summary of the MASCC/ISOO mucositis guidelines is available online (www.mascc.org/ mucositis-guidelines). “The MASCC/ISOO clinical practice guidelines support the use of new agents in patients receiving head and neck radiotherapy, based on available evidence. These agents include benzydamine mouthrinse [for] patients receiving radiotherapy up to 50 Gy without concurrent chemotherapy (based on level I evidence) and a suggestion for low-level laser therapy (LLLT) in patients receiving radiotherapy in the absence of concurrent chemotherapy (based on level III evidence). The guidelines also support the use of 0.2% morphine mouthwash (level III evidence) and 0.5% doxepin mouthwash (level IV evidence) to reduce pain due to oral mucositis,” Lalla reportedLevels of evidence are defined in Table 1. CRUCIAL CARE Dental care before initiation of radiotherapy or chemoradiation is crucial, experts agree. “Absolutely every patient who is about to undergo radiation therapy that includes the mouth should have a pretherapy dental evaluation,” Sonis emphasizes. Preradiation dental evaluation and treatment is a mandatory component of treatment plans, he says.

The major goals of dental evaluation are twofold, he explains: first, identification and elimination of existing or potential sources of infection, and second, elimination of any sources of mucosal irritation such as fractured teeth. “We still don’t know if, or how, the microbiome might contribute to mucositis, although we do know that attempts at reducing the oral bacterial

LLLT's impacts on tumor behavior have not yet been studied. load have, generally, proved inadequate in preventing mucositis,” cautions Sonis. “Having said that, we also know that patients with clean mouths do better than those with poor hygiene. Since dentures act both as irritants and as ‘bug habitats and transporters,’ their use should be limited in patients who are receiving radiation therapy and prostheses should be cleaned and disinfected.” “Oncology nurses are in an excellent position to screen for oral health problems prior to radiotherapy,” Sonis says. “Simple screening questions to assess the level of dental health (last

dental visit, pain, ability to eat, etc.) are often helpful.” Every patient should be screened before radiation begins, he reiterates, “preferably in enough time to allow for healing from any [dental] procedures that are required.” At least 3 weeks should elapse between a tooth extraction and commencement of radiation, he advises. NOVEL TREATMENTS The field has experienced repeated disappointments over seemingly promising therapies that did not pan out.9 Fortunately, the research and development pipeline is rich, says Sonis. “I’m optimistic that we’ll have an effective preventive treatment within the next few years.” “A large variety of agents have been tested for radiation-induced oral mucositis, with most proving ineffective,” Lalla agrees. “This is an active field of research and a number of agents are in clinical trials or other stages of development for radiation-induced oral mucositis.” Low-level laser therapy might reduce the incidence of severe chemoradiationassociated oral mucositis, and improve quality of life for patients with head and neck cancers.10 However, Sonis and others urge caution because LLLT’s impacts on tumor behavior have not yet been studied. Anti-inf lammatory agents are a promising strategy for preventing and treating oral mucositis, but the evidence base is immature and inconsistent, note Lalla and coauthors of the MASCC/ISOO Mucositis Study Group’s systematic review of the published literature.11 (Based on that review, misoprostol mouthrinse is not recommended for preventing radiotherapy-associated oral mucositis in patients with head and neck cancer, however.11)

36 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

Sonis is particularly enthusiastic about the promise of genomics and personalized medicine in treatment planning and prevention of oral mucositis and other regimen-related toxicities, as increasing understanding of the biologic pathways involved in the pathogenesis of radiation- and chemotherapy-mediated injury continue to emerge. “Using genomics to identify or define patients at risk for oral mucositis is close to becoming a clinically actionable reality,” Sonis tells Oncology Nurse Advisor. “Identification of genes associated with drug metabolism has been available for some time and has focused on genes controlling the enzymes for mucotoxic agents [such as] 5-FU and methotrexate. And while genetic defects associated with drug metabolism are relatively rare, their identification and association with toxicity risk served as proof-of-concept.” “Utilization of sophisticated analytics that recognize that genes are ‘team players’ has enabled genomic risk prediction for mucositis among patients receiving conditioning regimens prior to stem cell transplant and [patients] receiving conventional chemotherapy regimens,” Sonis adds. Toxicity risk prediction should also be applied to patients whose treatment plan includes radiation therapy, he explained. CONCLUSION

5. Villa A, Sonis ST. Mucositis: pathobiology and management. Curr Opin Oncol. 2015;27(3): 159-164. doi:10.1097.CCO.0000000000000180. 6. Holt ER, Potts T, Toon R, Yoder M. Oral manifestations of cancer therapy: advice for the medical team. J Nurse Pract. 2015;11(2):253-257. 7. Seiler S, Kosse J, Loibl S, Jackisch C. Adverse event management of oral mucositis in patients with breast cancer. Breast Care (Basel). 2014;9(4):232-237. doi:10.1159/000366246. 8. Allison RR, Ambrad A, Arshoun Y, et al. Multiinstitutional, randomized, double-blind, placebo-controlled trial to assess the efficacy

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

of a mucoadhesive hydrogel (MuGard) in mitigating oral mucositis symptoms in patients being treated with chemoradiation

REFERENCES

therapy for cancers of the head and neck.

1. Lalla RV, Saunders DP, Peterson DE.

Cancer. 2014;120(9):1433-1440.

Chemotherapy or radiation-induced oral

9. Lalla RV, Choquette LE, Curley KF, et al.

mucositis. Dent Clin North Am. 2014;58(2):

Randomized double-blind placebo-

341-349. doi:10.1016/j.cden.2013.12.005.

controlled trial of celecoxib for oral mucositis

2. Jensen SB, Peterson DE. Oral mucosal injury caused by cancer therapies: current management and new frontiers in research. J Oral Pathol Med. 2014;43(2):81-90. doi:10.1111/jop.12135.

in patients receiving radiation therapy for head and neck cancer. Oral Oncol. 2014;50(11):1098-1103. 10. Antunes HS, Herchenhorn D, Small IA, et al. Phase III trial of low-level laser

3. Lalla RV, Bowen J, Barasch A, et al; Mucositis

therapy to prevent oral mucositis in head

Guidelines Leadership Group of the

and neck cancer patients treated with

Multinational Association of Supportive

concurrent chemoradiation. Radiother

Care in Cancer and International Society

Oncol. 2013;109(2):297-302. doi:10.1016/

of Oral Oncology (MASCC/ISOO). MASCC/ ISOO clinical practice guidelines for the

j.radonc.2013.08.010. 11. Nicolatou-Galitis O, Sarri T, Bowen J, et al;

management of mucositis secondary to

Mucositis Study Group of the Multinational

cancer therapy. Cancer. 2014;120(10):

Association of Supportive Care in Cancer/

1453-1461. doi:10.1002/cncr.28592.

International Society of Oral Oncology

4. Eilers J, Million R. Clinical update:

Oncology nurses bear the brunt of symptom prevention and management, Sonis notes. “They are generally the health care providers with the most

FIND US ON

contact with patients. Consequently, oncology nurses are often best placed to convey to patients the importance of oral health in the context of overall well-being and to teach, assess, and monitor all aspects of oral health during treatment. Importantly, by recognizing abnormalities in the clinical appearance of the mouth or in symptom complexes associated with it, oncology nurses can catalyze aggressive intervention to prevent small problems from becoming disasters.” ■

(MASCC/ISOO). Systematic review of anti-

prevention and management of oral

inflammatory agents for the management

mucositis in patients with cancer. Semin

of oral mucositis in cancer patients.

Oncol Nurs. 2011;27(4):e1-e16. doi:10.1016/

Support Care Cancer. 2013;21(11):3179-3189.

j.soncn.2011.08.001.

doi:10.1007/s00520-013-1847-y.

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COMMUNICATION CHALLENGES

They Chose You to Ask

©THINKSTOCK

Ann J. Brady, MSN, RN-BC

Normal barriers to interpersonal behavior are breached, and this allows a safe place for [patients] to ask important questions.

e’ve all been there before: in the middle of performing a nursing task, a patient places their hand on your arm and looks at you imploringly, then asks a question you are not sure how to answer. What do you do? All the what if ’s fill your mind. What if I say the wrong thing? What if the patient/family/doctor gets upset with me? What if I don’t really know the answer? What if I know the answer but am afraid to tell the patient? What do I do? No one wants to be the bearer of bad news. Because our work experience means we have taken care of other patients with the same diagnosis, we know better than they do what is coming next. That puts even more pressure on us when a patient asks a difficult question.

CASE I was asked to give a short presentation on communication at a recent nursing skills day. My target audience was bedside nurses on

the oncology unit, many of whom I knew well. My comfort level was high. I knew my topic and my audience. I put together a brief PowerPoint presentation and planned for several role-playing scenarios. And then I did what I always do in this situation: I practiced. Driving in the car, I practiced my presentation out loud. Walking the halls of the hospital, I imagined the questions I might be asked and, in my head, silently practiced answers. What we do as nurses is actually called a practice, which in itself is interesting. It implies, correctly I believe, that what we do as nurses is constantly changing and evolving. We are continuously adjusting. Our practice is built on our education and on our work experiences. While I was planning the role-playing scenarios, I went around to bedside nurses and asked, “What is the most difficult question you are asked by patients?” Without exception, it was when a patient asked, “Am I dying?” There were other challenging questions such as “Should I do more chemo?” and “My family wants me to keep fighting but I’m tired. What do I tell them?” and “What is going to happen next?” I incorporated those questions into my talk. But before discussing how to answer difficult questions, I thought it important to step back and consider why patients ask such difficult questions, specifically why they ask nurses. Asking nurses is not a random choice. DISCUSSION Nurses spend more time with patients than any other member of the health care team, and they do so in some of the most intimate ways. Holding an emesis basin, helping them to the bathroom, changing dressings, to name

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COMMUNICATION CHALLENGES

There are so many questions and so many potential answers. It is likely we may not have all the answers. That’s okay.

just a few. Normal barriers to interpersonal behavior are breached, and this allows a safe place for them to ask important questions. Sometimes they ask the nurse a question they plan to ask the doctor, practicing it on us. It may be less frightening to ask the nurse first, then work up to asking the doctor what they want to know—and don’t want to know at the same time. But there is more to it than proximity or familiarity. When I have a question to which I do not know the answer, I am particular in how I decide whom to ask. I want to ask someone who is knowledgeable on the subject. I want it to be someone who is approachable. Someone who is safe to ask, and someone who will take the time to answer. And I choose the person, zooming in on the one I think meets those requirements. Then I practice and revise how I will ask my question. I pick an opportune time. For a patient that may be when a nurse is changing a bedpan or giving a medication. CAPC Center to Advance Palliative Care Fast Fact #26 has a section especially focused on communication and the importance of clarifying the question a patient asks.1 It may feel like a dodge to ask a patient what they are asking, but a big part of answering the question is having a full understanding of the meaning, of making sense of the question. Using the explanatory model, you ask questions that focus on what, why, how, and who.1 If a patient asks, “Am I dying?” there are several ways to answer. Unlike many of

JOIN THE CONVERSATION • What do you do when a patient asks a question you are not sure how to answer? • Have you ever revisited a question your patient asked you?

ON THE

WEB

Go to OncologyNurseAdvisor.com/challengesaskedyou to talk with your colleagues about how you handle a situation in which a patient asked a question that was difficult to answer.

the nursing tasks we perform, there is not a prescribed right way to answer questions, as there is for med passing or dressing changes. You might ask, “What do you think?” and follow their lead. Or you might respond, “What is your understanding of what is happening?” or “Why are you asking? Has something happened or did someone say something to make you ask that question?” It may feel like an imperative to answer the question right away, but we can revisit almost all of the questions. You may say, “I’ve been thinking about that question you asked me earlier and I’d like to talk more about it.” Or even, “I don’t think I answered your question very well. Can we take another try at it?” The difficult questions about prognosis are also an opportunity to uncover some of the deeper concerns of the patient and family. What the patient wants may differ from what the family wants or is hoping for. When they ask a question is also an opportunity to ref lect it back. What would you like to do with the time you have left? Who would you like to have with you at this time? What would you like to do in regards to treatment? This may also be a time to discuss advanced directives; if it comes to a time where you want to stop treatment, what other treatments would you consider? Would you like to be intubated? What does CPR look like to you? There are so many questions and so many potential answers. It is likely we may not have all the answers. That’s okay. We can pause before answering; pause long enough to remind ourselves they chose you to ask. They picked you. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California. REFERENCE 1. Hallenbeck J. Fast Fact #26: The explanatory model. CAPC Center to Advance Palliative Care Web site. https://www.capc.org/fast-facts/26explanatory-model/. Accessed October 2, 2015.

44 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

THE TOTAL PATIENT

Adolescent Stem Cell Donors: Benefits, Burdens, and Risks of Being a Lifelife for a Sibling Bette Weinstein Kaplan

young person decides to donate stem cells to an HLA-matched sibling in need of a bone marrow transplant. It is such a selfless gift. But for an adolescent in the midst of the emotional turmoil that comes with that age, just how easy a decision is it to give such a complex gift? A multidisciplinary team explored the conundrum with the goal of identifying how to help these generous persons through a ver y diff icult decision.1 The team members were Meaghann S. Weaver, MD, MPH, from the Department of Oncology; Ashley Carr, CCLS, from the Child Life Program; and Brandon Triplett, MD, from the Department of Bone Marrow Transplantation and Cellular Therapy, all from St. Jude Children’s Research Hospital in Memphis, Tennessee; and Douglas S. Diekema, MD, MPH, attending physician and director of education for the Treuman Katz Center for Pediatric Bioethics at the Seattle Children’s Research Institute in Seattle, Washington.1 Potential sibling donors of hematopoietic cells often feel they exist in the shadows cast by their ill brother or sister. The care team has a unique responsibility to bring the sibling donors’ situation into the light. Theirs is not an easy gift to give, and potential donors’ decision process is often emotionally fraught.1

MAKING THE DECISION Human leukocyte antigen (HLA) matching is the most important donorrelated determinant of a patient’s outcome. When researchers compare rates of complications, relapse, and survival among patients who receive an HLA-matched donation from a sibling vs. an HLA-matched donation from an unrelated source, the results are obvious: the outcome is more successful when the donor is a sibling. Risks for graft-versus-host disease, rates of infection, and treatmentrelated mortality are all lower, and survival rates are far superior. Weaver and colleagues report that because of the success rates, sibling donors have been recruited in 39% to 48% of all childhood bone marrow transplants to date, and that number is on the rise.1

Potential donors should be aware of side effects that may affect their decision. Deciding to donate may not be easy for a young person, since donating stem cells is a challenging, time-consuming, and sometimes painful procedure. Even the initial evaluation is difficult, as any

potential donor begins the process with extensive medical tests and physical examinations. Any donor must have normal pulmonary, hepatic, renal, and cardiovascular function and be free of active infectious diseases. The donor sibling must also be immunocompatible with the patient. Once compatibi l it y has been determined, the donor sibling needs to decide if she or he wants to continue the process. A person making a decision like this requires a considerable amount of information and support. To that end, the transplant team should explain the next steps. UNDERSTANDING THE PROCEDURE

Potential donors must understand that hematopoietic progenitor cells are collected from the their bone marrow or peripheral blood, and their experience can vary from discomfort to actual pain. For example, once donor eligibility is confirmed and the sibling decides to proceed, the next step is usually administration of granulocyte-colony stimulating factor (G-CSF). This medication stimulates the bone marrow to increase the proliferation of hematopoietic stem cells prior to leukapheresis, the procedure used to collect white blood cells. G-CSF is usually administered as a daily subcutaneous injection, and

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2015 • ONCOLOGY NURSE ADVISOR 45

THE TOTAL PATIENT it can cause muscle aches, headache, nausea, and bone pain. If the G-CSF is successful, leukapheresis is usually the next step. Educating the potential donor is vital. The donor sibling should know that each session of leukapheresis takes approximately 4 hours. The procedure might be painful and cause racing heartbeat, low blood pressure, clotting difficulty, low platelets, and temporary symptomatic hypocalcemia. In addition, the donor could be exposed to blood products during the priming of the apheresis equipment. When actual bone marrow collection is used instead of leukapheresis, 50% of sibling donors experience pain severe

Sibling donors may feel as if they have no say in the matter of being a donor. enough to require analgesia, 9% experience lumbar region stiffness, and 7% of the young donors have sore throats as a result of intubation.1 In addition, if the sibling is much larger in size, the donor may need a blood transfusion, although this complication occurs less frequently.1 Potential donors should be aware of these possible side effects. These factors

may affect their decision to continue with the process. DO THEY REALLY HAVE A CHOICE?

Weaver and colleagues point out that donor siblings face a two-fold dilemma: their sibling is a chronically ill child, and they have been asked to take on the responsibility of serving as a donor.1 They may experience guilt feelings if the sibling does not survive. Even when given all the facts, sibling donors may feel as if they have no say in the matter of being a donor. In a study at one institution, 5 of 15 siblings reported feeling as though their opportunity to say “No” was limited.2 They perceived themselves as having no choice due to expectations from doctors and family members. Furthermore, 9 siblings in that study also felt their own religious beliefs prevented them from declining to donate.2 The situation is even more difficult for nondonor siblings. In a study that included 44 siblings, 21 donors and 23 nondonors age 6 to 18 years, of surviving pediatric bone marrow transplant recipients, nondonor siblings showed significantly more school problems than donor siblings, and one-third of nondonor siblings reported a moderate level of posttraumatic stress reaction.3 Fortunately, medical centers are increasingly utilizing child life

specialists to educate, prepare, and lend support to sibling donors. They provide counseling and therapeutic activities to address the emotional distress that accompanies the unique situation. Whether a young person is able to donate stem cells for an ill sibling, and regardless of the outcome, the oncology nurse and other transplant team members are in an exceptional position to aid and guide the donor sibling through this incredibly difficult time. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Weaver MS, Diekema DS, Carr A, Triplett B. Matched marrow, sibling shadow: The epidemiology, experience, and ethics of sibling donors of stem cells [published online ahead of print July 31, 2015]. J Adolesc Young Adult Oncol. 2015;4(3):100-104. doi:10.1089/ jayao.2014.0051. 2. MacLeod KD, Whitsett SF, Mash EJ, Pelletier W. Pediatric sibling donors of successful and unsuccessful hematopoietic stem cell transplants (HSCT): a qualitative study of their psychosocial experience. J Pediatr Psychol. 2003;28(4):223-230. 3. Packman WL, Crittenden MR, Schaeffer E, et al. Psychosocial consequences of bone marrow transplantation in donor and nondonor siblings. J Devel Behav Pediatr. 1997;18(4):244-253.

Advance Your Skills and Improve Your Patients’ Treatment Outcomes The 2nd annual ONA Navigation Summit on April 7-9, 2016, Orlando, FL, will provide you with the insight and tools to evolve as a top-notch oncology navigator. Use code “ONAFA30” to save $30 on your registration fee.

www.ONANavigationSummit.com 46 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

THE PATIENT’S VOICE

Dedicated Discovery Cinde J. Dolphin

he postanesthesia care unit (PACU) nurse roused me from my anesthesia cloud gently. As I came to, I found that I now had odd attachments, like octopus extensions with bulbs. An uncomfortable, unexpected wakeup. Slowly, I started grasping at the foreign objects. I had just undergone a lumpectomy procedure. Some excision had occurred. But, what were these new additions? I didn’t count on gaining appendages. How did these new hitchhikers plan to travel with me? A Jackson Pratt (JP) drain is an awkward experience for any cancer patient. Just when life is swirling out of control, new issues arise regarding sleeping, bathing, and regaining mobility. I was handed safety pins. Seven surgeries over 20 years, each successive time I was handed safety pins to support the JP drains, and poorly at that. For example, when the drains were pinned to my gown, I rolled onto them at night. Ouch. Or, a nurse forgot the drains were attached to the gown and inadvertently yanked at the sutures when changing my gown. Ouch, again. Showers meant allowing gravity to pull the bulbs the length of the

tube (Figure 1). Ouch, once again. Could there be a simple, inexpensive way to allow people to return to normal life while sporting medical drains? After my fourth cancer diagnosis and third breast reconstruction, I wanted a solution. A way to support the suspended drains—heavy with mucus and blood clots—that did not aggravate my wound area. My plastic surgeon suggested a Home Depot canvas apron. The idea received rave reviews from the nursing team at the UC Davis Medical Center. The ICU crew appreciated the apron pockets, since it meant not spending valuable time searching for my drains to clear fluids. Also, the centralized access permitted me to sleep through the night, even when it was necessary for staff to check drain fluid levels. I agreed the apron helped. But the canvas construction was stiff and certainly would not work when bathing. The dilemma took me to a Dollar Store. I am a fan of dollar stores. I’ve often discovered gems there, such as the fine lingerie washing bags, right next to the sewing notions. These were soft mesh bags with a zipper closure. Three for a dollar! Continues on page 51

Figure 1: Drain bulbs pull on insertion sites

Figure 2: The Medical Drain Carrier

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Patient’s Voice Continued from page 47

My nephew is a talented seamstress. Really, he is. He has fabricated car interiors, soft pillows for kids, and now he was going to produce drain carriers for postsurgery patients (Figure 2). After testing a couple of different models, we came up with a prototype. We had trimmed the lingerie bags to approximately 11 inches long and 7 inches high, a more convenient size. I had purchased double-fold bias tape at the fabric store, and we stitched it along the upper edge, leaving 18-inch extensions on each side for waist ties. I laundered the bags, and offered to provide them free to patients at UC Davis Medical Center’s plastic surgery office. Almost immediately, patient feedback was very positive. “I did not take it off for the whole time I had the drains. We showered, lounged, walked (a bit gingerly), and slept together,” said Suzi from Folsom, California. “It was so easy to wash in the shower, allowing me to also wash the drains. It was a great gift and blessing at a very difficult time. Thank you so much!” Over the next couple of months, the carrier was improved. I found a vendor who could meet my specifications and individually wrap each carrier in sealed cellophane bags. The UC Davis Med Center PACU Nurse Manager, Gary Kurtz, ordered 100 carriers, and they were issued to each patient who underwent a procedure that included a drain. His medical team said the carriers helped them do their

jobs, allowing them to see drains easily and keep them organized around the patient’s torso area. More patients provided positive feedback. “(I) was dreading going to work and out in public with the drain. Now you’ve given me my life back!” said Barb in Sacramento, California. I am happy because now there is a solution for keeping the drains attached comfortably. There may be a better solution, but I think this is a good start. My mission statement is: To meet the needs of postsurgery patients—providing safe and easy management of tubes and medical drains installed during surgery. Now, I feel I am getting closer to achieving that mission. Patients can purchase medical drain carriers (patent pending) online at www.MedicalDrainCarrier.com. A random twist of fate brought an opportunity for those with limited resources to benefit from the drain carrier. A dear friend started a funding campaign to provide the carriers to low-income patients at no cost to them. More details are available by emailing us at MedicalDrainCarrier@gmail.com. Hospitals can purchase the carriers in quantities of 25 or more. The experience of having cancer made a huge impact on my life. The world’s best medical providers, especially the oncology nursing team, cared for me. My respect for the nursing profession multiplied exponentially with each diagnosis. I hope developing the medical drain carrier can be a token of my appreciation, dedicated to an exceptional community of health care professionals. ■

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2015 • ONCOLOGY NURSE ADVISOR 51

FROM

©THINKSTOCK

cancer diagnosis often brings about feelings of fear and an x iet y. But when the diagnosis is triple negative breast cancer (TNBC), the patient often experiences even more anxiety when she learns about the high recurrence rates and lack of targeted drug treatments available for this particular subtype of breast cancer. Helping patients understand the disease, how it is treated, and dispelling myths related to it are important factors to improve their ability to cope with their diagnosis. Tr iple negative breast cancer accounts for 15% to 20% of breast cancer cases.1 TNBC is a subtype of breast cancer that lacks typical receptors: estrogen, progesterone, and HER2. Treatments such as tamoxifen and trastuzumab (Herceptin) act as receptor blockers, which slow or stop cancer growth and prevent recur rences. However, because TNBC lacks receptors, these targeted therapies are ineffective treatments for TNBC. Throughout the treatment process, doctors and nurses should explain the diagnosis and treatment plan to patients in simple, understandable terms. Providing written information is also helpful as many patients are overwhelmed and in shock during their initial appointments. Living Beyond Breast Cancer offers the “Guide to Understanding Triple Negative Breast Cancer,” which provides useful information about the disease, treatment options, and posttreatment recommendations.

Tips and Tools for Coping With TripleNegative Breast Cancer Victoria Puzo, LMSW

Myth: Triple negative breast cancer is a death sentence. Fact: TNBC is not a death sentence! Make sure patients know there are effective treatments for this disease, and people can survive. Be sure to point out that TNBC is particularly sensitive to chemotherapy, and many clinical trials are available if standard treatment is ineffective.2 Myth: Triple negative breast cancer is difficult to treat. Fact: Although there is a lack of targeted treatment options, an array of effective chemotherapies are out there to treat this disease.2 Patients should know that just because receptor blockers are not effective for this type of breast cancer, this does not mean their cancer is untreatable.

FOSTERING RESILIENCE AND RECLAIMING CONTROL

DISPELLING MYTHS People who read about TNBC on the internet will likely be bombarded by scary information. Talking to patients about what they read online and dispelling misinformation they come across is important. These are the most common myths, with corresponding facts that can be given to discount them.

Normalizing and validating patients’ concerns will go a long way in promoting a sense of resilience. Nurses can also build resiliency in patients by fostering active participation in their treatment plan. Resilience can also come from a strong support network. Ask patients to identify their supports and urge them to reach out when help is needed. Patients often lose their sense of purpose during treatment, especially if they stop working. They should be encouraged to identify new roles or activities that are meaningful to them such as cultivating their spirituality, getting involved in the cancer community, or identifying a new hobby that is tolerable during treatment. Continues on page 54

Talking to patients about what they read online and dispelling misinformation they come across is important. 52 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

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FROM Patients may feel out of control, pa r t icu la rly once t reat ment is complete and they are dealing with the unknown. When the risk of recurrence is high, they are frequently preoccupied with the idea of their cancer coming back. Patients can be taught mindfulness and to concentrate on the here and now. What can bring them joy, comfort, or happiness today? It can be something as simple as a visit from a loved one or taking a soothing bath after treatment. Help patients focus on the things they can control. Patients can choose to follow a healthier lifestyle and exercise more. They can choose to surround themselves with supportive people. They can come up with an aftercare plan that might include a schedule of follow-up appointments, lists of doctors or nurses they can call in case they have a pressing concern, or tips on how to cope with posttreatment anxiety. Patients’ anxiety will likely lessen once they have a sense that they can control some parts of their life. FINDING SUPPORT

Just like patients with most other cancers, patients with TNBC may

benefit from peer support from their peers. However, patients with TNBC typically feel they cannot relate to women with other types of breast cancer because of the vast differences in treatment options and the higher risk of recurrence. Because they often feel disconnected from the general breast cancer population, many TNBC patients

Connecting TNBC patients with disease-specific support is the key. have unmet psychosocial needs. 2 Connecting patients with TNBCspecific support is the key. This can be challenging, as TNBC support groups are limited. Here are some helpful support resources that can be referred to patients. Peer matching services These programs can connect a person to another woman who experienced TNBC: Living Beyond Breast Cancer,

888-753-5222; SHARE, 866-8912392; Cancer Hope Net work, 877-467-3638. Online support groups and forums

Online communities allow women to connect from all over the world. CancerCare, 800-813-4673, provides an online TNBC patient support group facilitated by an oncology social worker. Triple Negative Breast Cancer Foundation, 877-800-TNBC (8622), hosts an online patient forum where people can ask questions and interact with other TNBC patients, caregivers, and survivors. I f a pat ient i s ex per ienc i n g persistent anxiety or depression, encourage her to pursue treatment from a mental health professional, such as an oncology social worker or psychiatrist. ■ Victoria Puzo is an oncology social worker at CancerCare. REFERENCES 1. Hartsock MA. Guide to Understanding Triple Negative Breast Cancer. 3rd ed. Haverford, PA: Living Beyond Breast Cancer; 2013. 2. LeBrasseur N, Van Epps HL. Targeting the triple threat. Cure. 2009;8(3):48-53.

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54 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2015 • www.OncologyNurseAdvisor.com

ASK A PHARMACIST

Cannabis, commonly known as marijuana

MS-associated pain in cancer patients; data on cannabis What are the most effective treatments for multiple sclerosis (MS) pain in patients with co-existing cancer requiring chemotherapy treatment? —Name withheld on request

Pain can be a frequent symptom of MS, occurring in approximately half of patients with the disease.1 Patients may experience acute or chronic pain described as burning, stabbing, pinsand-needles, or other symptoms. Pain may be neuropathic in nature, or nonneuropathic and secondary to other MS complications such as spasticity. Medications to treat MS pain include those used for other forms of neuropathy, such as tricyclic antidepressants, other antidepressants such as the serotonin and norepinephrine reuptake inhibitors, antiepileptic drugs, opioids, antispasmodic agents, and topical

agents.1 Patients with MS pain may also require additional medications to modify their disease course and manage other MS symptoms. These disease-modifying medications, and other agents used to treat MS symptoms, should be managed by providers with experience treating MS. Selection of an appropriate agent to treat pain caused by MS should be done with consideration of the symptom severity and their overall MS disease course. As with other medications, agents used to control MS symptoms and modify the course of the disease can have a variety of interactions with cancer treatment. These interactions may increase drug toxicity, reduce efficacy of MS or cancer therapy, or cause adverse effects that overlap with the symptoms of MS. Management of these interactions and other issues involved in the care of these patients depends on many patient specific factors such as treatment modalities being utilized, goals of cancer therapy, symptom etiology and severity, and the clinical significance of the interaction. Therefore, management should be done with consideration of these and other needs and should include input from Oncology, Neurology, and other appropriate health care teams. Managing the needs of patients with multiple medical conditions can truly be a balancing act. When a patient’s medical conditions are this significant, clear and timely communication between the patient’s care teams is critical to ensure

coordination of care and promote the best outcomes for the patient. Patients periodically ask me about the use of marijuana to treat cancer. Is there any data about this? —Name withheld on request

Most of the clinical data on marijuana in cancer treatment is related to using marijuana or specific compounds of marijuana in the management of cancer-related side effects.2 As far as anticancer effects of marijuana, some studies utilizing cancer cell lines or mice cancer models have demonstrated potential anticancer activity. Translating this data to anticancer activity in humans is complicated by multiple factors. Marijuana consists of thousands of chemical compounds and varies from strain to strain, complicating the process of isolating potential active compounds to produce reliable, consistent doses. The bottom line for patients is that current data do not support using marijuana for anticancer effects. ■ REFERENCES 1. Maloni H. Pain. National Multiple Sclerosis Society Web site. http://www.nationalms society.org/Symptoms-Diagnosis/MSSymptoms/Pain. Accessed October 5, 2015. 2. Cannabis and Cannabinoids–for health care professionals (PDQ). National Cancer Institute Web site. http://www.cancer.gov/about-cancer /treatment/cam/hp/cannabis-pdq. Updated August 28, 2015. Accessed October 19, 2015.

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

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