ONA November/December 2017 by Haymarket Media

November/December 2017

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

DIET AND NUTRITION

FEATURE G-CSFs: A Review of Dosage, AEs, and Nurse Management

RADIATION & YOUR PATIENT Challenges of Combining RT and Immunotherapy

COMMUNICATION CHALLENGES Navigating Complex Conversations

THE TOTAL PATIENT Prosthetic Nipple Crowns Survivorâ&#x20AC;&#x2122;s Quest for Improved Breast Reconstruction

FROM CANCERCARE Navigating the Breast Cancer Posttreatment Transition

ASK A PHARMACIST End of ESA APPRISE; PARP Inhibitors and Leukemia

Using Nutrition-Based Strategies to Manage the Effects of Treatment Dietary guidance is an effective strategy for managing adverse effects of treatment.

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

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Oncology Nurse Advisor (ISSN 2154-350X), November/December 2017, Volume 8, Number 6. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

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

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 7

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CONTENTS 10

IN THE NEWS • Adverse Event Rates Influence Trial Dropouts • Frozen Gloves Reduced Chemotherapy-Induced Peripheral Neuropathy • Maintenance Lenalidomide Prolongs Progression-Free Survival in CLL • Propolis Effectively Prevents Chemotherapy-Induced Oral Mucositis • Nivolumab, Ipilimumab Combination Improved OS in Advanced Cancer • Bevacizumab-awwb Is First FDA-Approved Biosimilar for Anticancer Therapy … and more

PALLONC 2017 • Patients Prefer Face-to-Face Communications • Oncologists, Patients Have Different Views on AML Treatment Outcomes, Prognosis • Pain Control of Bone Metastases More Easily Achieved With Nurse-Led Education … and more

ONCOLOGY NURSE ADVISOR FORUM • Treating Intractable Hiccups in Advanced Cancer, Palliative Care Setting • New Class of Clinical Trial Enhances Research on Cancer Care Delivery

45 FIND US ON

November/December 2017

NAVIGATOR NOTES Building Successful Cancer Awareness Events John Schieszer

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8 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

www.OncologyNurseAdvisor.com

JOURNAL REVIEW No Benefit to Extensive Cancer Screening in Unprovoked Venous Thromboembolism

Although unprovoked VTE may be a sign of occult cancer, a meta-analysis showed no benefit to extensive cancer screening. John Schieszer, MA

Nurse Survey Identifies Adverse Events Related to Handling Chemotherapy

FEATURES 22 Nutritional Interventions for Managing Adverse Effects Susan Bratton; Jessica A. Iannotta, MS, RD, CSO, CDN

G-CSFs: A Review of Dosage, AEs, and Nurse Management Maria Guerrero, DNP, APRN, ANP, AOCNP

3 Factors Impede Survivorship Care in Primary Care Practices Bette Weinstein Kaplan

Bette Weinstein Kaplan

RADIATION & YOUR PATIENT Challenges of Combining RT and Immunotherapy Bryant Furlow

FROM CANCERCARE What SUPPORT Can Do For Families Coping With Cancer During the Holidays

These SUPPORT tips can help caregivers of patients with cancer make the most of seasonal activities with their loved ones. Mayra D. Sandoval, LMSW

COMMUNICATION CHALLENGES Navigating Complex Conversations Ann J. Brady, MSN, RN-BC

THE TOTAL PATIENT Prosthetic Nipple Crowns Survivor’s Quest for Improved Breast Reconstruction Bette Weinstein Kaplan

PUBLISHERS’ ALLIANCE Complications and Management of Coagulation Disorders in Leukemia Patients

Four case studies that illustrate a range of coagulation disorders that can develop to elucidate the rationale and process of specific treatment options for leukemia. Blood and Lymphatic Cancer: Targets and Therapy

FROM CANCERCARE Navigating the Breast Cancer Posttreatment Transition Stacy Lewis, LMSW, ACHP-SW

Breast Cancer Recurrence Not a Deterrent for Survivors Who Wish to Conceive

John Schieszer, MA

ISSUES IN CANCER SURVIVORSHIP

JOURNAL REVIEW Repurpose Statins to Combat Cancer STAT CONSULT Acalabrutinib (Calquence)

Megan Garlapow, PhD

This study explored the potential for pregnancy and breastfeeding among women who survived breast cancer and the impact of pregnancy on disease recurrence.

Investigators determined oncology nurses’ perception of their risks in handling and administering cytotoxic chemotherapy.

ASK A PHARMACIST End of ESA APPRISE; PARP Inhibitors and Leukemia Lisa A. Thompson, PharmD, BCOP

ON THE

WEB

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 9

IN THE NEWS Adverse Event Rates Influence Trial Dropouts Participants enrolled in phase 1 cancer trials who experience adverse events (AEs) are more likely to withdraw from the study. Phase 1 trials determine the safety profiles of treatment regimens as well as phase 2 dosing and doselimiting toxicities. Although supporting evidence exists for why patients enroll in phase 1 studies, what motivates them to withdraw is unclear. In this retrospective review, investigators analyzed the records of 255 patients with solid tumors who enrolled in phase 1 clinical trials from the Oncore clinical trials database. Baseline characteristics were recorded, including race, age, gender, cancer type, performance status, and whether trials evaluated cytotoxic therapy or noncytotoxic therapy. The frequency, nature, and grade of adverse events experienced by patients were also noted. Patients were enrolled in phase 1 studies for a mean duration of 78.4 days, and 23% of patients were in the study for 30 days or less. On average, 25.1 adverse events were experienced, including constitutional, gastrointestinal, and pain; 46.9% Adverse events was were nonlaboratory — ie, events presented as sympthe second most toms and not only as abnormal laboratory tests results. common reason for The most common reason for clinical trial withdrawal discontinuation was disease progression, followed by adverse events. Approximately 13% of patients cited other reasons as cause for discontinuation; however, on further review, 41.7% of these cases were associated with symptom burden. Greater AE rates were found to have a significant positive association with shorter study duration. The investigators conclude that availability of interventions that reduce adverse event burden may extend participants’ duration on trial, impact recommended doses in phase 2 trials, and improve quality of life for participants on phase 1 trials.

Frozen Gloves Reduced ChemotherapyInduced Peripheral Neuropathy Quality of life (QOL) for patients with chemotherapy-induced peripheral neuropathy (CIPN) was improved by wearing frozen gloves during treatment. The gloves reduced symptoms even though long-term differences in neuropathy were not observed. CIPN is a common adverse effect experienced by patients with cancer treated with oxaliplatin and taxanes. The purpose of this study was to evaluate the efficacy of wearing frozen gloves during chemotherapy for CIPN prevention. In this study, 180 patients with newly diagnosed cancer receiving oxaliplatin, docetaxel, or paclitaxel therapy were randomly assigned to wear frozen gloves on both hands during treatment (intervention group) or not wear gloves

(control group). The EORTC-QLQ CIPN20 and EORCTQLQ C30 assessments were used to measure patient-reported CIPN and QOL at baseline (T0), after 3 cycles (T1), at the end of chemotherapy (T2), and after 6 months (T3). The intervention group experienced less neuropathy at T1 and T2 compared with the control group. However, by T3, there was no significant difference between the 2 groups. Patients in the intervention group also trended towards greater ease in day-to-day activities, and had significantly lower motoric problems. QOL on EORTC QLQ-C30 subscales for physical, role, cognitive, social functioning, symptom scales, fatigue, and appetite loss were all reported to be significantly higher in patients wearing frozen gloves vs those not wearing the gloves. Read more at http://bit.ly/2w5aenG.

10 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

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

Nivolumab, Ipilimumab Combination Improved OS in Advanced Melanoma Patients with advanced melanoma experienced significantly prolonged overall survival (OS) when treated with nivolumab plus ipilimumab (N+I) compared with nivolumab or ipilimumab alone. For the phase 3 Checkmate 067 study, researchers assigned patients with advanced melanoma 1:1:1 to receive nivolumab 3 mg/kg plus placebo, ipilimumab 3 mg/kg plus placebo, or nivolumab 1 mg/kg plus ipilimumab 3 mg/kg followed by nivolumab 3 mg/kg. Patients were stratified according to programmed death ligand 1 (PDL-1) status, melanoma BRAF mutation status, and metastasis stage. Median OS was not reached in the N+I arm at minimum follow-up of 36 months, and was 37.6 months in the nivolumab group and 19.9 months in the ipilimumab group. OS at 3 years was 58%, 52%, and 34% in the N+I, nivolumab, and ipilimumab groups, respectively, and safety profiles remained consistent with those of previous studies across the 3 regimens. Read more at http://bit.ly/2hznWtM.

FDA Approves Supplemental Indication for Lanreotide Depot for Carcinoid Syndrome The US FDA announced the approval of a supplemental indication for lanreotide depot injection (Somatuline Depot) to reduce frequency of short-acting somatostatin analog rescue therapy in the treatment of carcinoid syndrome. Carcinoid syndrome is a constellation of symptoms that occur secondary to a carcinoid tumor releasing chemicals in the bloodstream. Patients may experience symptoms such as flushing, diarrhea, facial skin lesions, difficulty breathing, and tachycardia. The FDA based its approval on the results of the phase 3 ELECT study (ClinicalTrials.gov Identifier: NCT00774930), for which investigators randomly assigned 115 patients with neuroendocrine tumors to receive lanreotide depot or placebo every 4 weeks. Study patients had access to short-acting

octreotide as rescue medication. The primary end point of the study was the percentage of days that patients did not utilize octreotide. Patients in the lanreotide depot arm had a significantly lower percentage of days when rescue octreotide was used compared with those in the placebo arm, which represented an absolute difference of –14.8%. The lanreotide arm had a significantly greater odds ratio of full or partial treatment success compared with placebo. Lanreotide was well tolerated, and the safety profile was comparable to previous findings. The most frequently reported adverse events were headache, dizziness, and muscle spasms. Read more at http://bit.ly/2z9tIwg.

Bevacizumab-awwb Is First FDA-Approved Biosimilar for Anticancer Therapy The US FDA granted approval to bevacizumab-awwb for the treatment of adult patients with certain brain, cervical, colorectal, kidney, or lung cancers. Bevacizumab-awwb is a recombinant IgG1 monoclonal antibody that binds to vascular endothelial Model of a VEGF growth factor (VEGF) and inhibits molecule angiogenesis. It is the first biosimilar approved in the United States for anticancer therapy. The FDA based its approval on evidence demonstrating that bevacizumab-awwb has no clinically significant differences from its reference product in terms of structural and functional characterization, data collected from animal studies, pharmacokinetic and pharmacodynamics profiles in humans, immunogenicity, and safety and efficacy data. However, bevacizumab-awwb has a boxed warning alerting prescribers and patients to the risk of gastrointestinal perforations, surgery and wound healing complications, and severe or fatal pulmonary, gastrointestinal, central nervous system, and vaginal bleeding. Read more at http://bit.ly/2z8lBxn.

For full news stories visit OncologyNurseAdvisor.com

12 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

cycle, whereas 5 patients in the control arm developed OM greater than grade 1 in the first cycle. The incidence of grade 1 and higher OM was the greatest in cycle 2 and cycle 5.

IN THE NEWS | PALLONC 2017

Physicians who communicated face-to-face with their patients without the use of computers were not only seen as being more compassionate, professional, and having better communication skills, they were also preferred as providers, according to study results presented at the 2017 Palliative and Supportive Care in Oncology Symposium. Electronic health records (EHR) are being utilized with increased frequency in health care, but the effect using computers during patient consultations may have on communication has not been explored. For this study 4 videos were prepared; 2 videos depicted different doctors in face-to-face interaction, and 2 depicted the doctors in a consultation with a computer. Researchers randomly assigned 120 patients with advanced cancer to watch 2 videos of patient-physician interactions. Both sets of videos had an identical script. After watching the first video, patients were asked to complete a questionnaire grading the physician’s professionalism (0=poor, 20=very good), compassion (0=best, 50=worst), and communication (0=poor, 70=excellent). The patients then watched a second video of the topic (face-to-face or computer) that they did not previously see by the different actor-doctor. After watching the second video, patients were asked to rate which physician they would prefer. Patients rated the face-to-face consultation as being more professional (median 19 vs 14), compassionate (median 9 vs 20), and communicative (median 65 vs 54) than the consultation using the computer. After watching the second video, 72% of patients reported preferring face-to-face communication. The researchers noted that although their study findings answer questions regarding patients’ perceptions regarding computer use in the examination room, how to address this issue needs further investigation. Read more at http://bit.ly/2ypcbR5.

Oncologists, Patients Have Different Views on AML Treatment Outcomes, Prognosis Patients with acute myeloid leukemia (AML) who are older than 60 years had optimistic outlooks for curation likelihood and an overestimation of treatment risks that were both at odds with the outlooks of their oncologists. The treatment of AML can be a difficult one to navigate especially for the elderly; therapy options are often risky and involve multidrug intensive chemotherapy with only a slight chance of a cure, or are palliative and noncurative. For this study, researchers enrolled 100 patients with AML to undergo intensive chemotherapy (50 patients) or nonintensive chemotherapy (50 patients). Three days after initiating treatment, patients and oncologists were given

questionnaires to evaluate their views on the likelihood of dying from treatment, and 1 month later their views on prognosis were assessed. Patients in both arms of the study reported feeling as though they were somewhat (63.0%) or extremely (28.3%) likely to die due to treatment. Their oncologists reported that it would be very unlikely (80.0%) that patients would die. Most patients expressed positive feelings about their prognosis; nearly 90% reported that they were somewhat or very likely to be cured. This stood in stark contrast to the opinions of their oncologists, who reported that the chances of cure were unlikely or very unlikely (74%). Read more at http://bit.ly/2gYuLo0. Continues on page 14

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 13

Patients Prefer Face-to-Face Communications

IN THE NEWS | PALLONC 2017

Significant reductions in health care costs were achieved by providing a palliative care consultation for patients with advanced cancer, and the benefit was greater with earlier consults. Previous studies have shown that patients with advanced cancer may experience some financial relief integrating palliative care with standard oncologic care, but these results were coincidental findings and have not yet been fully explored. This matched case-control study enrolled a total of 2576 patients with advanced lung, colorectal, breast, or prostate cancer. Patients who received a palliative care consultation were matched with patients who did not, and their costs before and after the consultation were evaluated to assess the economic effect of the palliative care consultation. The health care costs for patients with advanced cancer 30 days prior to receiving the palliative consultation were comparable for both groups: $12,881 and $12,335 for patients who received palliative care consultations and those who did not, respectively. Total costs incurred in the 120 days after the intervention, were $9604 for patients who received standard oncology care vs $6880 for patients who received a palliative care consultation (costs reduced by 28%). In addition, financial relief was greater the earlier the palliative care consultation was provided. A palliative consultation occurring at least 4 weeks from death resulted in cost reduction of $5362 vs $975 reduction when a palliative consultation occurred 7 days prior to death. Read more at http://bit.ly/2z7N6r1.

Adolescents With Cancer May Derive Benefit From Skills-Targeted Interventions Adolescents and young adults with cancer may benefit from receiving interventions that develop various skills that help them cope with issues that accompany their illness. For this study, investigators randomly assigned 100 adolescents and young adults with cancer ages 12 to 25 years old 1:1 to the “Promoting Resilience in Stress Management” (PRISM) intervention (one-on-one and facilitated family meetings that attempt to improve stress management, goal-setting, cognitive reframing, and meaning making) or to nondirective usual psychosocial care. Patient-reported

outcome (PRO) surveys were completed at enrollment and at 6 months after the intervention. The primary outcome for the study was patient-reported resilience and the secondary outcomes included health-related quality of life, hope, and psychosocial distress. Of the enrolled patients, 92% completed the surveys at baseline. A similar loss in patient participation was observed in both arms, primarily due to death and/or medical complications; 72% of patients in the PRISM arm and 76% of patients in the standard psychosocial arm completed the 6-month PRO survey. Patients in the PRISM arm achieved improvements in all outcomes targeted by the intervention: resilience, quality of life, hope, and distress. Read more at http://bit.ly/2lJJAQn.

Pain Control of Bone Metastases More Easily Achieved With Nurse-Led Education Patients undergoing radiotherapy for painful bone metastases achieved better pain control quicker if they also received nurse-led education (NLE) on pain. Although radiotherapy is an effective treatment for patients with painful bone metastases, patients do not always NLE was written and verbal interventions. achieve adequate pain control. The purpose of this study was to evaluate the effect nurse-led education would have in controlling pain compared with care-as-usual (CAU). For this phase 3 study, researchers randomly assigned 354 patients with uncontrolled pain 1:1 to receive NLE or CAU prior to starting radiotherapy. NLE comprised a structured interview assessing patient knowledge of pain; verbal and written education materials on pain; and follow-up calls at 1, 4, 8, and 12 weeks to address questions associated with pain. Patients receiving CAU only received leaflets on radiotherapy, opioid use, and cancer pain. At 12-week follow-up, approximately 52% of patients completed the study. More patients in the NLE arm reported achieving a pain score of less than 5 on the number rating scale compared with patients in CAU arm (66% vs 52%, respectively). Patients in the NLE arm also reported reaching a pain score of less than 5 in 31 days vs 54 days for the patients in the CAU arm. Read more at http://bit.ly/2h6J9OT.

14 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

Palliative Care Associated With Lower Costs in Advanced Cancer

ONCOLOGY NURSE ADVISOR FORUM QUESTIONS & ANSWERS

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

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

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

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

TREATING INTRACTABLE HICCUPS IN ADVANCED CANCER OR THE PALLIATIVE CARE SETTING What are some medications that can be used to treat intractable hiccups? — Name withheld on request Intractable hiccups — also referred to as hiccoughs in the literature — can be especially problematic when treating patients with advanced cancer or in the palliative care setting. Multiple agents have been tried to treat this condition. Baclofen (Lioresal), chlorpromazine (Thorazine), and metoclopramide (Reglan) are the medications most frequently used in clinical practice for the treatment of intractable hiccups, with varying efficacy. Chlorpromazine is the only agent that is FDA-approved for the treatment of intractable hiccups. It and metoclopramide are thought to treat hiccups by modulating dopamine; metoclopramide also promotes gastric emptying, which may be helpful. Baclofen is thought to treat hiccups through its effects on the neurotransmitter GABA. Multiple other agents have been reported to have some effects in this setting, including anticonvulsants, proton pump inhibitors (PPIs), corticosteroids, nifedipine, and inhaled lidocaine; however, I generally begin treatment with baclofen, chlorpromazine, or metoclopramide as these agents have more supporting literature for this use. I typically select an agent based on the patient’s other comorbidities and other medications they may be taking. For example, metoclopramide or baclofen may not be appropriate for some patients with renal dysfunction. Baclofen and chlorpromazine can cause sedation and should be used with caution in patients prone to falls. All of the above options can interact with other medications patients in this treatment setting may be receiving, and should be reviewed by a pharmacist to detect any potentially harmful drug interactions. — Lisa A. Thompson, PharmD, BCOP

NEW CLASS OF CLINICAL TRIAL ENHANCES RESEARCH ON CANCER CARE DELIVERY I have heard about a new class of clinical trials called Cancer Care Delivery Research (CCDR). What is a CCDR clinical trial and how does it differ from clinical trials that test new drugs? Are nurses involved in these trials? How do I find out more? — Name withheld on request Cancer care delivery research is a new program of clinical research offered through the National Cancer Institute (NCI) Community Oncology Research Program (NCORP). The focus is on improving the delivery of cancer care for patients throughout the disease trajectory. These trials involve the development of novel care delivery models, use of technology, coordination, and the collaboration of care. CCDR examines the healthcare team as well as patient knowledge, attitudes, and behaviors; and healthcare utilization and outcomes such as costs, length of stay, and readmission. Oncology nurses are often involved in CCDR trials because their knowledge of all aspects of cancer care delivery is both broad and specific. You can find out more about this type of research by visiting the NCI Division of Cancer Control and Population Sciences website (https://healthcaredelivery.cancer.gov/ccdr/). — Leah A. Scaramuzzo, MSN, RN-BC, AOCN

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 15

he role of an oncology navigator is to provide guidance and help patients achieve optimal outcomes. Part of their mission is to educate the lay public. So, Oncology Nurse Advisor asked some oncology navigators what do they think makes for a successful cancer awareness or community outreach program? PERSONAL, FUN, FAMILY FRIENDLY

Frank dela Rama, RN, MSN, CNS, who is with the Palo Alto Medical Foundation in Northern California, said he believes one of the first steps is to make take a personal approach. He said some of his medical center’s most successful events have involved people sharing their journey through cancer. For a prostate cancer awareness event, several prostate cancer survivors shared their stories. Two of the men underwent surgery and 2 others opted for radiation therapy. The men told their stories from diagnosis through treatment and into survivorship. “This was followed by a Q&A session with the audience, with a urologist and radiation oncologist, to address any medical questions. The focus was definitely on the shared experience of cancer, and the message really hit home for those attending,” dela Rama told Oncology Nurse Advisor. dela Rama said making sure the event is fun makes all the difference. He said people should be excited about attending. “We were lucky enough to have a local hotel and champagne producer sponsor a breast cancer event, featuring

Building Successful Cancer Awareness Events John Schieszer

a dinner with champagne pairing. The event quickly sold out each year we hosted this. It was a great way to gather interest in our organization and our mission in the local community,” dela Rama explained. A couple of cancer survivors made brief presentations during the dinner. However, most of the time was simply dedicated to enjoying food and

drink. Another suggestion he has is to market your event early, often, and everywhere. “As soon as any event has been planned, spread the word in every way possible. For our breast cancer nonprofit, it starts with the board of directors letting their friends, family, and close networks know about the event. Social media campaigns should message frequently, especially nearer to the date of the event,” said dela Rama. If tickets are being sold, then it might be worth considering early bird discounts or discounts for tickets purchased in bulk. Another tip from dela Rama includes asking the audience in advance what they would enjoy. He recommends making phone calls and asking potential attendees what they would want at an event. “They can often give you a crucial perspective that can easily be overlooked by an event planning committee,” explained dela Rama. For a survivorship event, his team polled several cancer survivors prior to the event, and they were able to suggest some small changes to the marketing materials. It also steered them in the right direction on several substantial aspects, such as event content, speakers, music, and exercise programs. Another suggestion is to make your event as family friendly as possible. Having activities for all ages is highly encouraged, especially for outreach events. This can be something as simple as having an ice cream stand or food truck at your event. dela Rama recommends making sure the program has parts geared towards patients, caregivers, and

First and foremost, understand the population’s characteristics, location, and identify their barriers to services. 16 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

NAVIGATOR NOTES

NAVIGATOR NOTES families. “Games, giveaways, and prizes are always great as people walk away with something to take home,” he said. Cynthia Cantril, RN, OCN, CBCN, MPH, is the director of Cancer Support Services for a medical center in Santa Rosa, California, and was the recipient of a Lifetime Achievement Award in 2016 from the Oncology Nursing Society (ONS). Cantril said when looking to build a successful cancer screening programs, engaging the support of community organizations that have wellness programs already established is a good idea. Working in a collaboration can be highly effective. “Market well in advance. Use community health clubs to host awareness events. Ask a cancer survivor to do a strong welcome message or presentation, and establish relationships with local radio stations to promote your event and give thanks,” Cantril told Oncology Nurse Advisor. EMBRACE COMMUNICATIONS TECHNOLOGY

Claudia Barajas, a community health educator at Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, said establishing community relationships has changed significantly in the last

5 years because of the Internet and smart phones. However, the need for education to the community about cancer prevention continues to be the same. Barajas said there are now more opportunities to disseminate information through different channels. Barajas stressed the importance of adapting and embracing social media. In-person interactions, however, remain the most effective way to

“Use the appropriate channels where they can be reached,” Barajas told ONA. engage community members in cancer messages. Among Barajas’ top tips for making a cancer awareness or community outreach program successful is: first and foremost, understand the population’s characteristics, location, and identify their barriers to services. Barajas recommends ongoing engagement between community members and providers with the goal of developing trust. She also highlighted the importance

of knowing the target audience and then disseminating information that speaks to them. “Use the appropriate channels where they can be reached,” Barajas told Oncology Nurse Advisor. “Keep in consideration, the cultural values of diverse populations, literacy level, and subject relevancy. Be personable, respectful, flexible, and ready to provide solutions and answers to their questions and needs.” Also vital, you need to hire people who can establish genuine communication with others. She said these people need to be interested in connecting with others, and they need to have a passion for helping others. Barajas said increasing the number of people accepting screening recommendations and seeking preventive cancer services requires a multistep approach. “Active distribution of culturally tailored information using the appropriate channels, accompanied with ongoing engagement between health providers and community members, will help improve awareness about cancer in community members, and after some time, will help improve knowledge about cancer,” said Barajas. ■ John Schieszer is a medical writer based in Seattle, Washington.

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FEATURE | Diet and Nutrition

Nutritional Interventions for Managing Adverse Effects A review of recommendations and advice on nutrition practices that can improve the cancer journey for patients, caregivers, and nurses.

SUSAN BRATTON; JESSICA A. IANNOTTA, MS, RD, CSO, CDN

fter a cancer diagnosis, the patient with cancer will meet many people on their journey, including health care and nonmedical professionals who can have a dramatic impact on the patient and caregiver experience. Although these people may influence the patient in a variety of ways, the oncology nurse is one of the most important points of contact. They provide a broad range of care to patients with cancer including medical management of side effects, basic guidance on nutritional implications of cancer treatment, and referrals to supportive services, as well as emotional support and encouragement. In addition, oncology nurses have ongoing and continual exposure to patients before, during, and after cancer treatment. To effectively educate patients during these critical points in their cancer journey, oncology nurses need to understand common nutritionrelated effects of cancer treatments. This article offers a practical review of evidence-based nutrition management of adverse effects and how to approach common nutrition-related scenarios.

Adverse events can be effectively managed with dietary guidance.

NUTRITION DURING CANCER TREATMENT Research extensively supports the role of nutrition in cancer. Yet, maintaining adequate nutrition status is often a challenge because patients face a variety of symptoms related to the cancer and its treatment. Metabolic rates are increased due to higher levels of inflammatory cytokines.1 Therefore, patients with cancer may require

22 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

higher amounts of calories and protein to maintain their body weight throughout treatment. However, decreased appetite and persistent nutrition-related adverse effects make maintaining adequate oral intake a significant challenge. Major surgeries to the head and neck or gastrointestinal areas, pain, fatigue, depression, and existing or lingering effects of cancer treatment also may impair nutritional status.1 Malnourished patients are more likely to develop infections due to lack of vitamins, minerals, calories, and protein to support the immune system.2 Early determination of a patient’s risk for malnutrition is important to help prevent rapid decline in nutritional status. Malnutrition is present in 15% to 80% of all cancer cases, and more prevalent with advanced stage cancers.3 It can occur from both the cancer itself as well as the treatment.3 Proper nutrition during cancer treatment can promote improved quality of life and performance status, result in less treatment toxicity and treatment breaks, and improve survival rates.4-6 Patients at high risk for malnutrition include those with lung, pancreatic, gastrointestinal, head and neck, or esophageal cancer, those with a weight loss greater than 5% of normal body weight, and those with persistent anorexia and/or significant vomiting or diarrhea.1 Oncology nurses’ strong clinical expertise enables them to more easily identify which patients are at risk for malnutrition and place referrals, and nurses who have a good understanding of nutrition can promote timely nutrition interventions. Early and ongoing nutritional intervention has been shown to help patients maintain or increase weight, stabilize or reverse weight loss, reduce postoperative complications, and improve appetite7-10; all of which may result in enhanced treatment tolerance and better outcomes.11 Many cancer centers employ a registered dietitian, designated by the credential RD or RDN, or a registered dietitian who is a certified specialist in oncology nutrition, designated by the credentials RD, CSO. Dietitians with the added credential of CSO are the ideal referral for cancer patients at risk for malnutrition or to address any nutritional concerns due to their additional clinical expertise in oncology nutrition. To earn a CSO, a dietitian is required to practice as an RD for 2 years, have 2000 documented practice hours in oncology services, and successfully complete a board exam, then attain recertification every 5 years. If a cancer center does not have a specialist dietitian on staff, the “Find a Dietitian” function of the Academy of Nutrition and Dietetics’ website (www.eatright.org) can help find a local oncology-credentialed dietitian.

STRATEGIES FOR NUTRITION-RELATED SYMPTOMS Cancer treatments have expected adverse effects that vary by drug, chemotherapy combination, and radiation treatment area. Patients may experience nausea, vomiting, changes in bowel habits, dysgeusia, xerostomia, dehydration, loss of appetite, weight loss, mucositis, pain, and/or fatigue. Because nurses are typically one of the first points of contact during a patient’s visit, your awareness of nutrition strategies that can help manage these symptoms is essential. The following evidence-based suggestions may help with the more frequently reported symptoms1: Nausea/Vomiting Encourage patients to use an antiemetic medication 30 to 60 minutes before consuming a meal for optimal benefit. Patients should be advised to avoid having an empty stomach for an extended period of time, especially if they are taking oral medications.

Because nurses are typically a first point of contact, your awareness of nutrition strategies that can help manage these symptoms is essential. Avoid consuming large meals and greasy, spicy, or very high-fat foods when nauseated. But recommend that patients avoid drinking large amounts of water at the same time as eating, but to hydrate well if fluids are lost during emesis. Advise patients to eat at regular mealtimes or create an eating schedule to avoid skipping meals. Ideally, patients should eat 5 to 6 small meals throughout the day, or at least every 3 to 4 hours. Suggest eating easily digestible carbohydrates such as crackers, toast, or dry cereal, to help settle nausea. Ginger has antinausea properties, but advise patients to use products containing real ginger root (eg, sliced ginger root, pickled ginger, ginger tea, ginger cookies, or ginger sucking candies). Ginger can also easily be added to soups and stir fry. Diarrhea Recommend that patients avoid greasy, fatty, or fried foods; alcohol; and large meals until diarrhea resolves. Patients who are sensitive to lactose may also need to limit or avoid dairy foods. Suggest patients increase their intake of soluble fiber when experiencing diarrhea. It acts like a sponge to absorb water in the gastrointestinal tract. Sources of soluble fiber are ripe bananas, quick cook oatmeal, mashed potatoes without skins, and unsweetened applesauce. Continues on page 24

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FEATURE | Diet and Nutrition Conversely, also recommend limiting intake of insoluble fiber because it adds bulk to the stool and encourages a bowel movement. Insoluble fibers include vegetables such as cabbage, Brussels sprouts, broccoli, spinach, and cauliflower; fruits; nuts; and whole grain foods. Fluids may be lost with excessive watery diarrhea. To replenish depleted electrolytes, advise patients to consume at least 8 to 10 eight-ounce cups of fluids per day. These fluids can be water, mild juices, unsweetened coconut water, and sports drinks or hydration powders (available in the pharmacy). Good dietary sources for improving potassium levels include avocado, ripe bananas, skinless white or orange potatoes, cantaloupe, cooked carrots, and asparagus tips. Constipation Advise patients to consume more high fiber foods to help resolve constipation. However, you need to emphasize that patients should increase their fluid intake when increasing fiber consumption to avoid further worsening constipation. High-fiber foods are fruits, vegetables, whole wheat and whole grain breads, rice, cereals, pasta, nuts, and legumes. Recommend starting the day with a high-fiber breakfast (eg, bran cereal with slivered almonds and mixed berries), hydration, and a warm beverage to encourage a bowel movement. But they should avoid gas-producing foods such as beans, corn, peas, and cruciferous vegetables (eg, broccoli, cauliflower) to prevent uncomfortable bloating. Encourage patients to engage in physical activity as tolerated. This can help promote regularity. Lack of Appetite/Anorexia Patients should be told to make the most of “mealtimes.” Eating meals at the same times every day can help patients avoid skipping meals and avoid frustration from concerned caregivers. They can maximize each bite by eating nutrient-dense meals such as a high-calorie smoothie (eg, Peaches and Cream Oat Smoothie), scrambled eggs with added cheese, tuna melt sandwich, creamy soups, steel cut oatmeal made with whole milk, and snacks such as cheese and crackers, trail mix, nut granola bars, or yogurt and fruit. If regular meals are overwhelming, suggest eating smaller meals 5 or 6 times per day. Assess the patient for the root cause of their appetite loss. Perhaps they are experiencing a treatment-related effect such as constipation, nausea, or mouth sores, which can be treated both medically and nutritionally. Treating these issues may help improve the patient’s appetite. Mouth Sores/Dry Mouth Advise patients to eat soft, moist foods such as creamed soups, casseroles, scrambled eggs, mashed potatoes, and tuna or egg salad, and to avoid foods that are overly acidic or spicy, such as tomato or citrus-based dishes and foods with spicy ingredients, because these foods

PEACHES AND CREAM OAT SMOOTHIE This recipe is appropriate for patients experiencing lack of appetite, nausea, vomiting or heartburn, constipation, diarrhea, and fatigue, as well as mouth sores, dry mouth, chewing or swallowing difficulty, taste aversion to sour foods, lack of taste, or smell aversions.

PREP TIME

5 minutes, serves 1.

INGREDIENTS 1/2 cup rolled oats 1/3 cup plain yogurt 3/4 cup milk 1 small peach, pitted or 1/2 cup frozen peaches

1/2 medium-size frozen or fresh banana, sliced 1 tablespoon ground flaxseeds pinch of salt

DIRECTIONS 1. Combine all the ingredients in a blender. 2. Blend and pour into a large cup or bowl. Note: if the patient is experiencing bloating, omit the flaxseeds. Sipping on a smoothie can help supplement added nutrition. The added ingredients in this smoothie also work as a small meal. Excerpted from Bratton S, Iannotta J. The Meals to Heal Cookbook. Copyright © 2016. Boston, MA: Da Capo Press / Lifelong Books; 2016.

can irritate their mouth. Suggest adding extra gravy, sauce, broth, or butter to moisten foods. Encourage patients to follow routine good oral care. Suggest using oral nutritional supplements as needed. Changes in Taste Recommend food substitutions to manage changes in taste, such as substituting poultry, fish, eggs, beans, tofu, or soymilk for red meats. Suggest eating foods chilled or at room temperature to limit offensive tastes, and patients experiencing metallic taste should use plastic utensils. Strategies for removing an unpleasant taste in the mouth include sip ginger ale, suck on hard candy, or add lemon juice. Routine good oral care can also help manage this effect. Neutropenia and Anemia Low blood counts, including leukopenia, neutropenia, and low hemoglobin levels, can occur during chemotherapy. Although no individual dietary change can directly improve leukopenia or neutropenia, patients

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should be strongly advised to follow food safety guidelines and practice good hygiene to prevent potential infection.12 Patients experiencing anemia should include a high-quality protein at each meal: Greek yogurt or eggs at breakfast; sliced turkey breast or tuna at lunch; and salmon, beans, or tofu at dinner; and snack on nuts, nut butters, and seeds between meals. Protein provides amino acids, which are the building blocks to generate new blood cells. Patients should increase their consumption of iron rich foods such as liver, red meats, poultry, leafy green vegetables, and beans/legumes. Vitamin C-rich foods such as red peppers, strawberries, and citrus fruits, eaten together with iron-rich foods, maximize iron absorption. In the past, patients were instructed to avoid all raw food, including raw fruits and vegetables, during neutropenia. More recently, food safety restrictions have been liberalized as this restriction has not been shown to reduce infections. Raw fruits and vegetables can be consumed if washed thoroughly, but patients should be instructed to avoid raw or undercooked meat, eggs, fish, unpasteurized cheese and milk products, and spoiled or expired foods. Best practices for food safety include avoid cross contamination of raw meats and produce, wash hands thoroughly when coming into contact with food, and avoid high-risk food sources such as salad bars and street vendors where risk of exposure to bacteria that can cause food-borne illness may be higher.13 FREQUENTLY ENCOUNTERED SCENARIOS

A significant amount of cancer research can be found in books, magazines, and on the internet; much of which is misinformation. Uninformed patients and caregivers can easily fall prey to unreliable and dangerous health-related guidance when seeking information on diet and nutrition for cancer patients. When patients express interest in questionable dietary information or practices, you should consult with oncology-credentialed dietitians. In addition, consult with patients’ physicians when pursuing new nutrition and/or supplement strategies. Ensuring you are prepared to address scenarios in which you are confronted by a patient or family member is also helpful. Patient is on a self-imposed restricted diet. Patients with cancer commonly change their diets, often drastically, to make dietary changes they believe will have a positive effect on the outcome of their cancer journey. These self-imposed restrictions are usually not warranted. If a patient is at nutritional risk due to the impact of treatment side effects, including weight loss, or poor appetite, encourage the patient to liberalize their diet to make staying well-nourished easier. Encourage a wellbalanced diet adequate in calories and protein during treatment to support the patient on their journey. A referral for a nutrition

consultation with an oncology-credentialed dietitian could be warranted to further evaluate. Family, friend, or caregiver is making dietary demands.

People who are close to the patient hope to help by researching or seeking out information. This frequently leads to an abundance of, and sometimes differing, opinions about the patient’s diet. Although being respectful of family, friends, and caregivers is important, you must honor the patient’s intentions, goals, and wishes. If necessary, you can help the patient and loved ones strategize on ways loved ones can be helpful, especially if dietary control is becoming stressful. Patient asks, “what should I eat at meal times?” Many patients with cancer want to be told exactly what to eat. Referring them to nutrition resources such as nutrition services at the cancer center, Savor Health, the American Institute for Cancer Research, the American Cancer Society,

Working closely with the oncologycredentialed dietitians can ensure that patients have early and ongoing access to nutritional counseling. and others can provide reliable and trusted information and support. If patients are looking for general healthy meals, some suggestions include: unsweetened Greek yogurt, eggs, oatmeal, or smoothies for breakfast; lentil soup, salads with beans or grilled chicken, and nutrient-dense smoothies for lunch; and a well-balanced meal with plenty of vegetables, lean animal or plant protein, and a whole grain carbohydrate for dinner. Referral to an oncology-credentialed dietitian for individualized meal planning is always worthwhile, as a dietitian can create a tailored meal plan that is specific to each patient’s unique nutritional needs and preferences. HEALTHY RECIPES FOR CANCER PATIENTS Because so many cancer patients ask the question of “what to eat,” we included 2 recipes to accompany these strategies: Cool Cucumber Avocado Soup and Peaches and Cream Oat Smoothie. Both recipes can be prepared in 15 minutes or less and are designed to be easily tolerated during cancer treatment. CONCLUSION Oncology nurses play a vital role in the interdisciplinary team, as they are often the advocate for patients as well as a trusted source of information, advice, and empathy. Having the tools and knowledge — most importantly an understanding of the role of nutrition in cancer care — to

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FEATURE | Diet and Nutrition COOL CUCUMBER AVOCADO SOUP This recipe is appropriate for patients experiencing lack of appetite, nausea, vomiting or heartburn, constipation, diarrhea, fatigue, mouth sores, dry mouth, chewing or swallowing difficulty, taste aversion to sweet or sour foods, lack of taste, or smell aversions.

Susan Bratton is founder and CEO and Jessica Iannotta is chief operating officer of Savor Health, a nutrition platform that offers dietary counseling and meal services for persons with cancer, based in New York City. REFERENCES 1. Lesser M, Ledesma N, Bergerson S, Trujillo E, eds. Oncology Nutrition for Clinical Practice. Chicago, IL: Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics; 2013. 2. Poor nutrition can affect infection risk in people with cancer. American Cancer Society website. https://www.cancer.org/treatment/treatments-

PREP TIME

15 minutes, serves 4.

with-cancer/how-nutrition-affects-risk.html. Accessed September 27, 2017. 3. Santarpia L, Contaldo F, Pasanisi F. Nutritional screening and early treat-

INGREDIENTS 2 avocados, peeled and pitted 1/2 medium-size cucumber, peeled and cut into smaller pieces 1 cup cold water 1/2 cup milk 2-4 tablespoons freshly squeezed lemon juice

and-side-effects/physical-side-effects/infections/infections-in-people-

2 ice cubes 1/2 teaspoon salt, plus more to taste (optional) Toppings: 1/2 cup chopped tomatoes, 2 teaspoons olive oil, chopped fresh chives, 3 sprigs fresh dill

DIRECTIONS

ment of malnutrition in cancer patients. J Cachexia Sarcopenia Muscle. 2011;2(1):27-35. 4. Bauer JD, Capra S. Nutrition intervention improves outcomes in patients with cancer cachexia receiving chemotherapy—a pilot study. Support Care Cancer. 2005;13(4):270-274. 5. Antoun S, Rey A, Béal J, et al. Nutritional risk factors in planned oncologic surgery: what clinical and biological parameters should be routinely used? World J Surg. 2009;33(8):1633-1640. 6. Gupta D, Lis CG, Vashi PG, Lammersfeld CA. Impact of improved nutritional status on survival in ovarian cancer. Support Care Cancer. 2010;18(3):373-381.

1. Place the avocado, cucumber, water, milk, 2 tablespoons of the lemon juice, and the ice cubes and salt in a food processor or blender. Blend until completely smooth. Season to taste with more lemon juice or salt. 2. Top with the chopped tomatoes, a splash of olive oil, chopped chives, and some dill.

7. Marin Caro MM, Gómez Candela C, Castillo Rabaneda R, et al.

Note: if the patient has mouth sores, nausea or heartburn, avoid the tomato topping

9. Ligthart-Melis GC, Weijs PJ, te Boveldt ND, et al. Dietician-delivered

[Nutritional risk evaluation and establishment of nutritional support in oncology patients according to the protocol of the Spanish Nutrition and Cancer Group]. Nutr Hosp. 2008;23(5):458-468. 8. Ottery FD, Kasenic S, DeBolt S. Volunteer network accrues >1900 patients in 6 months to validate standardized nutritional triage. Proc Am Soc Clin Oncol. 1998;17:A-282, 73a. intensive nutritional support is associated with a decrease in severe postoperative complications after surgery in patients with esophageal cancer. Dis Esophagus. 2013;26(6):587-593. 10. Dobrila-Dintinjana R, Trivanovic D, Zelić M, et al. Nutritional support in patients with colorectal cancer during chemotherapy: does it work? Hepatogastroenterology. 2013;60(123):475-480. 11. Odelli C, Burgess D, Bateman L, et al. Nutrition support improves

support their patients in a multidisciplinary way is essential. This includes enhanced awareness of the risk factors for malnutrition, learning appropriate and up-to-date tools to screen patients for nutritional risk, and guiding patients through their nutritional concerns. Working closely with the oncology-credentialed dietitians within your area can ensure that every patient has early and ongoing access to nutritional counseling. In doing so, patients can achieve and maintain an optimal nutrition status to improve their treatment outcomes and maximize their quality of life. ■

patient outcomes, treatment tolerance and admission characteristics in oesophageal cancer. Clin Oncol (R Coll Radiol). 2005;17(8):639-645. 12. Dyer D. White blood count & diet. Oncology Nutrition, a dietetic practice of the Academy of Nutrition and Dietetics, website. http://www. oncologynutrition.org/erfc/eating-well-when-unwell/white-bloodcount-diet/. Accessed September 27, 2017. 13. Food Safety for People with Cancer. Washington, DC: United States Department of Agriculture; 2006. https://www.fsis.usda.gov/shared/ PDF/Food_Safety_for_People_with_Cancer.pdf?redirecthttp=true Accessed September 27, 2017.

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FEATURE | Side-Effect Management

G-CSFs: A Review of Dosage, AEs, and Nurse Management These agents, used to correct or prevent neutropenia due to induction or high-dose chemotherapy, present nursing challenges of their own. MARIA GUERRERO, DNP, APRN, ANP, AOCNP

Digitally colorized scanning electron micrograph of redcolored human neutrophils entrapping bacteria.

he immune system consists of 2 types of immunity: innate and adaptive. Innate immunity is described as the immune system that initially presents and is an immediate response. It works by providing the first line of defense from infectious processes. The adaptive immune system is more complex and slower to respond. It is responsible for recognizing foreign antigenic substances. The adaptive immune system is further subdivided into humoral and cellular immunity.1 This article focuses on innate immunity because it plays an important role in host recognition of and response to bacterial, fungal, and parasitic pathogens. Innate immunity is composed mostly of phagocytes in the granulocyte and monocyte lines, which include polymorphonuclear leukocytes, circulating monocytes, and tissue-based macrophages. Neutrophils are phagocytes. They ingest and kill invading bacteria, releasing cytotoxic, chemotactic, and inflammatory mediators at sites of infection.2 The development of cytokines to enhance phagocytic function and alter host defense has been ongoing since the mid-1960s. Four different cytokines have been described: granulocyte colony stimulating factor, granulocyte/macrophage colony stimulating factor, macrophage colony stimulating factor, and interferon. For this article, I will focus on granulocyte colony-stimulating factors (G-CSFs),

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such as filgrastim and derivative products including pegfilgrastim and biosimilars.3 HOW G-CSFS WORK AND THEIR USE

Granulocyte colony-stimulating factors, in general, are a bone-marrow–derived growth factor produced by monocytes, macrophages, fibroblasts, and endothelial cells. Initially, G-CSFs were described as a hematopoietic glycoprotein that regulates cell cycle activation, proliferation, terminal maturation, and survival of the myeloid lineage in the bone-marrow–producing mature polymorphonuclear cells (neutrophils). These growth factors are stimulated in the bone marrow to produce neutrophils.3 G-CSF binds to the cell surface of hematopoietic cells in the bone marrow and stimulates neutrophil progenitor cell proliferation and differentiation. This mechanism of action helps speed neutrophil growth and maturity, increasing the number of mature neutrophils that are released into the circulation.4 The most common clinical uses for G-CSFs in patients with lymphoma is to accelerate neutrophil recovery after induction or high-dose chemotherapy and for bone marrow/peripheral stem cell transplantation. Patients with lymphoma who are receiving chemotherapy, especially high-dose immunosuppressive therapy, are at risk for developing neutropenia. Neutropenia, defined as an absolute neutrophil count (ANC) less than 1000 neutrophils/mcL, commonly occurs in patients receiving myelosuppressive chemotherapy regimens for lymphoma. NCI classifies the disorder in 5 grades ranging from 0 to 4, with 4 being the most severe grade (ANC <500 neutrophils/mcL).5 Neutropenic patients may develop fever, a major adverse effect of chemotherapy that can result in treatment delays and dose reductions, leading to overall poor outcomes. Today, G-CSFs can reduce the risk of neutropenic fever.6 Smith and colleagues identified the possible indications of therapeutic use of G-CSFs: patients at risk for sepsis syndrome; patients age 65 years or older; patients at risk for profound neutropenia (defined as less than or equal to 0.1); neutropenia that is expected to last more than 10 days; patients at risk for pneumonia, invasive fungal infections, or other infections; hospitalization with fever. G-CSFs are indicated for patients with poor performance, extensive prior therapy, and poor nutritional status.7 These agents are also indicated for use as primary prophylaxis in patients at high risk due to medical history, age, disease characteristics, or myelosuppressive regimens. Other uses include stem cell mobilization and support after stem cell transplantation.5

ADVERSE EFFECTS ASSOCIATED WITH G-CSFS Skin Reports of skin reactions with G-CSF use include

rash, urticaria, and facial edema. Delayed hypersensitivity reactions have been reported with pegfilgrastim use. Most skin reactions are believed to be caused by neutrophilic infiltration into the epidermis and dermis, and are associated with macrophage accumulation in the skin resulting in a maculopapular rash, annular desquamative eruption, or granulomatous dermatitis.8

The patient’s skin should be carefully examined prior to injection of G-CSFs to ensure early recognition of skin reactions should they occur. Respiratory Respiratory symptoms such as wheezing and dyspnea are believed to occur due to polymorphonuclear mediated lung damage from neutrophil accumulation in the lung. Bleomycin is believed to cause pulmonary effects; however, in combination with a G-CSF, the harm to the lung is intensified due to resultant pulmonary edema and fibrosis.8 Other possible respiratory adverse effects include acute respiratory distress syndrome, alveolar hemorrhage, and hemoptysis. Cardiovascular Potential cardiovascular adverse effects include tachycardia, hypotension, anaphylaxis, and capillary leak syndrome. Bone pain The most commonly reported adverse effect is bone pain. Lambertini and colleagues identified 4 main causes for bone pain in patients receiving G-CSFs9: • Differentiation, maturation, and functional stimulation of mature cells caused by qualitative and quantitative expansion of the bone marrow. This leads to secretion of cytokines that create a form of communication between cells, which creates an inflammatory cascade that recruits other cells to make colony-stimulating factors (CSFs). • CSF stimulation of CSF receptors located on primary afferent nerve produces peripheral nociceptor sensitization to nociceptive stimuli through the development of morphological and electrophysiological changes in nerve fibers. • CSFs stimulate and recruit inflammatory cells that can sensitize their own peripheral nerve fibers, contributing to nerve remodeling through the release of inflammatory cytokines. Continues on page 30

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FEATURE | Side-Effect Management • The direct effect of G-CSFs on bone metabolism. These agents may activate osteoclasts and osteoblasts with the final effect being bone resorption. Additional adverse effects Clinicians administering G-CSFs should be aware of these other adverse effects that have been reported, including splenic rupture, myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML), leukocytosis, thrombocytopenia, and elevated LDH levels.

Patients receiving G-CSFs should be assessed for pain. Patient education should include potential causes of pain and use of pain-relieving agents. Imaging G-CSFs can also influence diagnostic studies such as nuclear imaging, specifically PET scans. Transient positive bone imaging changes have been reported due to increased activity of the bone marrow in response to growth factor therapy.

DOSAGE AND ADMINISTRATION Filgrastim is available in vials, single-use prefilled syringes, or in multipacks of vials or syringes. Pegfilgrastim is available in vials, prefilled syringes, or a new wearable delivery device the nurse places on the patient that administers the drug the next day. Prophylactic use of G-CSF is recommended for patients whose risk for febrile neutropenia is greater than 20%. In cases of curative or life-extending treatment, filgrastim or biosimilar dose is 5 mcg/kg (rounding to the nearest vial or syringe defined by institution weight limits). Doses are usually started the next day (24 hours) or up to 4 days after completion of chemotherapy and continue until nadir ANC recovery is met or near to normal levels by laboratory standards.5 Recommendations call for pegfilgrastim administration 24 hours after completion of chemotherapy. Because pegfilgrastim is a longer acting form of filgrastim, a single 6-mg dose is sufficient for each chemotherapy cycle.5 NURSING MANAGEMENT White and colleagues stress the importance of making sure the patient and family understand the chemotherapy regimen and the risk for neutropenia and infection.10 Education for the family members and/or the caregivers should include risk factors associated with neutropenia and signs and symptoms of infection. In addition, the importance of undergoing

weekly laboratory tests for blood cell counts, strict adherence to hand washing practices, and avoidance of people who may be infectious or ill when the patient has reached nadir. Adverse skin reactions are associated with G-CSFs, in particular filgrastim. The patient’s skin should be carefully examined prior to injection of G-CSF medications to ensure early recognition of skin reactions should they occur. Pegfilgrastim is a glycosylated form of filgrastim, which therefore has a prolonged effect, reduced renal clearance, and usually few side effects. However, immediate type hypersensitivity reaction with filgrastim and biosimilars have been reported.11 G-CSF therapy should continue until nadir ANC recovery is met. The need for continuing therapy is determined via weekly blood counts, depending on chemotherapy regimen. Patients receiving G-CSFs should be assessed for pain. Patient education should include potential causes of pain and use of pain-relieving agents, such as antihistamines. Acetaminophen and NSAIDs are avoided due to their risk of masking fever, which may be one of the first signs of infection. However, if pain is severe, acetaminophen, NSAIDs, or opioid may be considered for pain management.12 Careful records regarding administration of G-CSFs are essential. These agents may influence diagnostic imaging results, leading to false positives. In addition to patient education on G-CSF therapy, patients using the new wearable device also need information on how the device works and how to troubleshoot potential problems. Their family and/or caregivers also need to be trained about how to manage the device. CONCLUSION Oncology nurses are responsible for maintaining a familiarity with existing therapies, their potential adverse effects, and available formulation and alternate options. They are also charged with being able to advocate for the patient in discussions with primary healthcare clinicians about the available options regarding G-CSF therapy, including alternate formulations, offering a better adverse effect burden; biosimilars, which may be more affordable than the originator drug; and novel administration methods, which may reduce the need for multiple clinic visits. ■ Maria (Rosie) Guerrero is a nurse practitioner at the University of Texas MD Anderson Cancer Center in Houston, Texas. REFERENCES The references are included in the online version of this article, available through this quick link: http://bit.ly/2zGQXha.

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FEATURE | Survivorship Care

3 Factors Impede Survivorship Care in Primary Care Practices A comparative case study of 12 practices identified the barriers to integrating comprehensive cancer-survivorship care services into primary care practices.

Onsite observance showed that primary care practices lacked information and support regarding survivor care.

BETTE WEINSTEIN KAPLAN

n 2005 the Institute of Medicine (IOM) recommended that primary care clinicians should be the leading providers of care for adult cancer survivors in the United States. The IOM report even described the specifics of such care.1 Happily, there are more survivors now since that report was published: on January 1, 2016, there were more than 15.5 million cancer survivors and that number is projected to be more than 20 million by January 1, 2026.2 However, primary care practitioners seem reluctant to manage the care of patients who are long-term cancer survivors. But what seems like reluctance is actually the result of several factors, according to a multi-institutional group that examined the issue. The results of their investigation address the problem and offer solutions.3 For their investigation, the researchers performed a comparative case study of 12 US primary care practices located in Colorado, Illinois, Maine, Pennsylvania, New York, and Washington, between March 2015 and February 2017. Each practice included internal medicine or family practice clinicians. One of 4 investigators spent 10 to 12 days in each location observing, conducting interviews with practice staff and cancer survivors, and collecting data. Onsite researchers analyzed office documents, field notes, and transcripts as they searched for examples of comprehensive survivorship care provided by each practice. They looked for “cancer survivors’ experiences of care in each practice, and the practice’s comprehensive approach to survivorship care. This included favorable conditions

32 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

and infrastructure, or the practice’s capacity to implement comprehensive survivorship care (eg, disease registries, care coordination, communication with specialists).”3 BARRIERS TO SURVIVORSHIP CARE Of the 12 practices the authors studied, they could not find one that provided services of any kind for cancer survivors. The care that each practice provided for cancer survivors was the same care provided for patients who were not survivors. What the investigators did find in all of the practices were 3 significant barriers to implementation of quality care for cancer survivors. Unrecognized clinical category None of the clinicians viewed cancer survivors as different from other patients, so cancer survivors were not considered to be a special group requiring a separate category of care. Except for knowing that they had to watch for the recurrence of cancer in these patients, the practitioners were often unfamiliar with specifics of survivorship care. Lack of actionable information Many patients did not arrive at the primary care practice with a detailed survivorship care plan. The clinicians found outdated and insufficiently detailed cancer histories and treatment recommendations, and they could not reach oncologists and other contacts from when the survivors had received their cancer treatment — which could have been many years prior. Survivorship has no code Because as yet there is no diagnostic code for survivorship, the survivors were neither identified nor tracked separately from the other patients in the practices’ electronic health records (EHR). This meant that clinicians had difficulty identifying them as a group who needed specialized survivorship services or care plans as conditions and treatments changed. One clinician reported regretting that there was no

efficient way to track the survivors to find out if any of them developed treatment sequelae or secondary cancers.3 In their report, the researchers suggest that correcting these barriers and codifying the clinical category of survivorship are important first steps to the adoption of treating the cancer survivor in primary care. CHANGE IS ON THE WAY The American Society of Clinical Oncology, the American Academy of Family Physicians, and the American College of Physicians collaborated on an annual symposium focusing on survivorship. The Cancer Survivorship Symposium: Advancing Care and Research was developed to encourage and support primary care and other subspecialty physicians who provide care to cancer survivors. Because uniform standards are not fully established, the symposium mission is to make a significant effort toward helping primary care clinicians understand the needs of survivors and develop comprehensive, coordinated care models to meet those needs. The symposium is scheduled for February 16-18, 2018, in Orlando, Florida. Additional information and registration links for this meeting is available at https://survivorsym.org. ■ REFERENCES 1. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2006. 2. Miller KD, Siegel RL, Lin CC, et al. Cancer treatment and survivorship statistics, 2016. CA Cancer J Clin. 2016;66(4):271-289. 3. Rubinstein EB, Miller WL, Hudson SV, et al. Cancer survivorship care in advanced primary care practices: a qualitative study of challenges and opportunities [published online September 25, 2017]. JAMA Intern Med. doi: 10.1001/jamainternmed.2017.4747

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www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 33

JOURNAL REVIEW

tatins could be used in combination with anticancer drugs, possibly adding a clinical benefit, according to researchers in Greece. They report that hypercholesterolemia and tumorigenesis are interrelated and studies are now warranted to investigate whether some statins should be part of combination or triple therapy in some tumor types. Writing in OncoTargets and Therapy, they argue that in vitro, in vivo, and clinical data now support a potential role for certain cholesterol-lowering drugs in treating a variety of cancers.1 THE STUDY

Panagiota Papanagnou, from Agios Savvas Cancer Hospital, Athens, Greece, and colleagues conducted a review of the antitumor activity of widely prescribed marketed antihypercholesterolemic drugs, statins, and ezetimibe. They report that bile acid sequestrants (cholestyramine, colestipol, and colesevelam) currently show no evidence of anticancer activity. The research team found that ezetimibe’s function goes beyond NPC1L1 regulation to interfering with tumor microvascularization. They propose that different pathways may be involved and merit further research. Simvastatin may have the ability to help combat non-small cell lung cancer (NSCLC), breast cancer, and renal cell carcinoma (RCC), the investigators reported. In addition, clinical data suggested that clinically relevant doses of simvastatin (40 mg/day) combined with

Repurpose Statins to Combat Cancer John Schieszer, MA

the conventional chemotherapeutic scheme of irinotecan with fluorouracil (5FU) and folinic acid (FOLFIRI) may benefit patients with metastatic colorectal cancer. Lovastatin appears to have capabilities for combating melanoma and several other cancers, including medulloblastoma and mesothelioma. It has shown particularly promising activity against NSCLC and prostate cancer. Atorvastatin may help combat pancreatic cancer and colon adenocarcinomas, and fluvastatin may have antitumor activity against RCC and leukemia. WHAT WAS LEARNED This current review examines the anticancer properties of drugs used in the management of hypercholesterolemia and points to a new way of viewing all marketed antihypercholesterolemic agents. Academic thoracic oncologist Jonathan Lehman, MD, PhD, an instructor in medicine in the

division of hematology/oncology at Vanderbilt University Medical Center in Nashville, Tennessee, said the idea of repurposing these agents is attractive because they have established safety and dosing regimens. They are also already approved by the US Food and Drug Administration. “This means that if they are effective, they could enter clinic faster. Unfortunately, many compounds and drugs appear very promising in early research, but do not work in clinical trials, or work in early clinical trials, but not in larger ones. Others only work in specific situations with specific cancers,” Dr Lehman told Oncology Nurse Advisor. So, what should an oncology nurse do when a patient asks if they should be on a statin? “My answer is that I would not start a statin in a patient for the purposes of cancer treatment or prevention outside of a clinical trial. If a patient has a medically indicated reason to be on a statin, and they are tolerating it well, then I would keep them on the statin during treatment,” said Dr Lehman. He said if the patient is a cancer survivor or is posttreatment and has medical indications for a statin, he would start a statin after discussion with their primary care physician. These agents are generally well tolerated, but they have potential adverse events. He said clinicians owe it to their patients to treat their cancer based on mature prospective clinical trials. “This ensures that when we treat patients, the care team and the patient can be confident that

Study results demonstrate that statins have antitumor activity in various solid-tumor cancers and leukemia; however, experts offer these caveats on using them to treat cancer — at least for now. 34 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

we are giving them more benefit than risk,” explained Dr Lehman. IMPLICATIONS FOR NURSES The researchers draw an analogy between statins and aspirin. They point out how aspirin is combined with caffeine to improve efficacy, and suggest a possible benefit of using statins in a similar fashion. Michael Fradley, MD, director of USF-Moffitt Cancer Center Cardio-Oncology Program, Tampa, Florida, said he thinks the idea is promising but it is too soon to know which statins would be effective and for which tumor type.

“We recognize that statins have many beneficial effects separate from lower[ing] cholesterol, including antiinflammatory properties. There are some data suggesting cancer patients on statins may have mortality benefits, however this is quite preliminary. We need large prospective studies to more fully evaluate this question,” Dr Fradley stated. He said oncology nurses should tell their patients that statins may have some benefits from an anticancer standpoint. However, at this time he does not recommend starting statins for this purpose. “However, if the patient is already taking a statin or needs to start the statin for an

appropriate medical reason, then there may be an additional antitumor benefit. We will hopefully be able to answer this question more completely in the future based on data from several ongoing clinical trials,” said Dr Fradley. ■ John Schieszer is a medical writer based in Seattle, Washington. REFERENCE 1. Papanagnou P, Stivarou T, Papageorgiou I, Papadopoulos GE, Pappas A. Marketed drugs used for the management of hypercholesterolemia as anticancer armament. Onco Targets Ther. 2017;10:4393-4411.

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 • Downloadable patient fact sheets

• Easy-to-use medical calculators • Comprehensive drug slideshows

Visit www.OncologyNurseAdvisor.com today. www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 35

STAT CONSULT Acalabrutinib (Calquence) Drug Type and Indication

• Acalabrutinib is a Bruton’s tyrosine kinase (BTK) inhibitor indicated for the treatment of mantle cell lymphoma (MCL) in adult patients who have received at least 1 prior therapy

Mechanism of Action

• Acalabrutinib is a small-molecule inhibitor of BTK that forms a covalent bond with a cysteine residue in the BTK active site, leading to inhibition of BTK enzymatic activity ——BTK is a signaling molecule of the B-cell antigen receptor and cytokine receptor pathways ——BTK signaling results in activation of pathways necessary for B-cell proliferation, trafficking, chemotaxis, and adhesion • Nonclinical studies demonstrated inhibition of BTKmediated activation of downstream signaling proteins CD86 and CD60 and inhibition of malignant B-cell proliferation and survival Dosage and Administration

• 100 mg oral (capsules) twice daily (approximately every 12 hours) • Swallow whole with water, with or without food ——Do not break, open, or chew capsules • If dose is missed by more than 3 hours, skip and take next scheduled dose ——Do not take extra capsules to make up for missed dose Dose Adjustments

• Interrupt acalabrutinib for grade 3 or greater non-hematologic toxicities, grade 3 or 4 thrombocytopenia, or grade 4 neutropenia lasting more than 7 days • Reinstate treatment upon resolution to grade 1 or baseline levels ——1st and 2nd occurrence: Resume at 100 mg twice daily

——3rd occurrence: Resume at 100 mg once daily ——4th occurrence: Discontinue acalabrutinib • If administered with ——Strong CYP3A Inhibitor: Avoid concomitant use ■■ If inhibitor will be used for short term (less than 7 days), interrupt acalabrutinib ——Moderate CYP3A Inhibitor: 100 mg once daily ——Strong CYP3A Inducer: Avoid concomitant use ■■ If inducer cannot be avoided, increase acalabrutinib to 200 mg twice daily ——Gastric acid reducing agents ■■ Antacids »» Separate dosing by at least 2 hours ■■ H2-receptor antagonists »» Take acalabrutinib 2 hours before taking H2RA ■■ Proton pump inhibitor »» Avoid coadministration Specific Populations

• Pregnancy ——No available data in pregnant women ——May cause fetal harm based on findings in animal studies • Nursing mothers ——Do not breast feed for at least 2 weeks after final dose • Pediatric ——Safety and efficacy not established • Geriatric ——No clinically relevant differences in safety or efficacy was observed between younger and older patients • Renal impairment ——No clinically relevant differences observed in patients

36 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

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

• Easy-to-use medical calculators

• Downloadable patient fact sheets

• Comprehensive drug slideshows

Visit www.OncologyNurseAdvisor.com today.

STAT CONSULT with mild or moderate renal impairment compared with normal function; has not been evaluated in patients with severe impairment or dialysis • Hepatic impairment ——No clinically relevant differences observed in patients with mild (Child-Pugh class A) or moderate (Child-Pugh class B) hepatic impairment compared with normal function ——Has not been evaluated in patients with severe impairment (Child-Pugh class C) Boxed Warnings and Contraindications

• None Cautions

• Atrial fibrillation and flutter ——Monitor and manage appropriately • Cytopenia ——Monitor complete blood counts monthly during treatment • Hemorrhage ——Monitor for signs and symptoms of bleeding and manage appropriately ——Risk may be increased in patients receiving antiplatelet or anticoagulant therapies ——Consider withholding for 3-7 days presurgery and postsurgery based on type of surgery and risk of bleeding • Infection ——Monitor for signs and symptoms of infection and manage appropriately ——Consider prophylaxis for patients at higher risk of infection • Second primary malignancies ——The most frequent second primary malignancy was skin cancer; advise protection from sun exposure Adverse Effects

• The most common adverse reactions (≥20% of patients) ——Anemia, bruising, diarrhea, fatigue, headache, myalgia, neutropenia, thrombocytopenia Drug Interactions

• Coadministration with strong or moderate CYP3A inhibitors may increase plasma concentrations of acalabrutinib, which may increase risk of toxicity • Coadministration with strong CYP3A inducers may decrease plasma concentrations of acalabrutinib • Coadministration with proton pump inhibitor, H2-receptor antagonist, or antacids may decrease plasma concentrations of acalabrutinib

What to Tell Your Patient

• Take acalabrutinib 2 times a day (approximately 12 hours apart) ——If you miss a dose, take as soon as you remember. If more than 3 hours have passed, wait and take next regularly scheduled dose ——Do not take extra capsules to make up for a missed dose • Swallow capsules whole with a glass of water ——Do not open, break, or chew the capsule • Tell your healthcare provider about all your medical conditions including ——Bleeding problems; breastfeeding or plans to breastfeed; heart rhythm problems; hepatitis B infection; infections; pregnancy or plans to become pregnant; recent surgery or plans to have surgery • Tell your healthcare provider about all medications you are taking including ——Prescription and over-the-counter drugs, vitamins, and herbal supplements • You may experience serious side effects, including ——Hemorrhage (bleeding) ■■ Report signs or symptoms of severe bleeding ■■ Acalabrutinib may need to be interrupted for a major surgery. ——Infection ■■ Report signs or symptoms suggestive of infection, including: fever, chill, or flu-like symptoms ——Decreased blood counts ■■ You will need to undergo periodic blood tests during treatment ——Secondary primary cancers ■■ Other cancers have been reported in patients receiving alacabrutinib, including skin cancer ■■ Use sun protection when outside ——Heart rhythm problems ■■ Report any signs of palpitations, lightheadedness, dizziness, fainting, shortness of breath, and chest discomfort • The most common side effects include ——Bruising, diarrhea, headache, muscle aches, tiredness • Report all side effects that you experience to your healthcare provider, especially if they persist or bother you. • Nursing mothers ——You should not breastfeed while receiving alacabrutinib and for at least 2 weeks after your final dose. ■ Prepared by James Nam, PharmD.

38 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

RADIATION & YOUR PATIENT

Challenges of Combining RT and Immunotherapy Bryant Furlow Cancer care is moving from the three pillars of cytotoxic chemotherapy, radiotherapy (RT), and surgery to regimens that include targeted biologic and immunotherapeutic agents. The combination of radiotherapy and immunotherapy has shown early promise against some advanced cancers, including evidence that radiation might sensitize some tumors that are initially resistant to immune checkpoint–inhibition immunotherapy. But these investigational regimens’ suspected synergies are likely complex and might involve overlapping toxicity profiles from each treatment modality.

mmunotherapies are rapidly expanding the treatment options available for advanced cancers, confronting

the ways malignant cells can overcome an effective antitumor immune system response.1-4 Unlike cytotoxic chemotherapy or radiotherapy, immunotherapy agents work by reprogramming patients’ immune systems and inhibiting tumors’ mechanisms of immunosuppression, such as the PD-1/PD-L1 and CTLA-4 immune checkpoint molecular pathways. Immunotherapy is already a standard of care in some settings and seems poised to come into routine clinical use in several others.3 Radiotherapy remains a mainstay of cancer therapy, with more than half of patients receiving radiation at some point in their treatment.2-5 Just as radiotherapy has long been used in combination with surgery and chemotherapy, combination regimens involving radiotherapy and targeted biologic or immunotherapies are now emerging treatment strategies.1-8 Radiotherapy was long assumed to kill tumors via DNA-damage-induced apoptosis or programmed cell death, but there is increasing evidence that it also affects tumor microenvironments and a number of facets of patients’ antitumor immunity.7,9-12 Some researchers argue that radiotherapy “may act as a primer for or stimulus to initiate or augment an immune-mediated antitumor response.”12 While still largely experimental, the evidence base for combined radiotherapy plus immunotherapy is rapidly evolving, and although data is accumulating, little is yet known about the specific toxicities experienced by patients undergoing these regimens. Already, patients are likely to have received both radiotherapy and immunotherapy during the course of their cancer treatments. It appears likely that in the near future, immunotherapy will become formally integrated with clinical radiation oncology.2

There remain significant unknowns that require careful study, however. Issues of acquired tumor cross-resistance may emerge over time, for example. Durable remission rates for patients treated with immune checkpoint inhibitors for non-small cell lung cancer (NSCLC) remain low (20% or less of patients treated), though the development of predictive biomarkers may in the future help identify which patients are most likely to benefit.12 The hope, bolstered by early research data, is that together, immunotherapy and radiotherapy can more effectively kill tumor cells than either treatment modality alone — possibly even systemically, and not just in irradiated tissues — and that early signs of synergy will be validated in well-designed clinical studies, allowing optimization of dosing, timing, sequencing, and combinatorial strategies.3,9-12

The evidence base for combined radiotherapy and immunotherapy is rapidly evolving. With increasing rates of patient coexposures to these treatment modalities and the development of rational, empirically supported combination regimens, oncology nurses will face an increasingly complex management task with patients who must be closely monitored for toxicities.2,3 In small cohorts of patients administered immune checkpoint inhibition for NSCLC, followed by thoracic radiotherapy, severe toxicities, and patient deaths have been reported.12,13 Continues on page 42

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 39

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RADIATION & YOUR PATIENT RADIOTHERAPY AND ANTITUMOR IMMUNITY

A connection between tumor radiosensitivity and antitumor immune competence has been recognized in laboratory mice for close to 40 years, with higher radiation doses needed to control tumors in immunosuppressed animals than in immunocompetent ones.2 With the development of cancer immunotherapy agents, isolated case studies and phase 1 and phase 2 clinical data on interleukin-2 (IL-2) with radiotherapy were reported in 2012 that together suggested possible synergies between radiotherapy and immunotherapies.2,8-12 Case reports have described patients treated with ipilimumab, a monoclonal antibody that targets the CTLA4 immune checkpoint pathway, and radiation.2,8,9 A phase 1 clinical study suggested that in a small cohort of patients, stereotactic body radiotherapy plus high-dose IL-2 for patients with skin and kidney cancer yielded higher tumor response rates than had been previously reported for IL-2 alone.11 Radiotherapeutic tumor control outside of irradiated target volumes (the socalled abscopal radiotherapy response) is thought to be rare in part because of tumors’ immunosuppressive microenvironments, providing a rationale for the combination of immunomodulating agents with radiation.5,12-14 Indeed, preclinical experiments strongly suggest that immuno-radiotherapy can induce systemic abscopal antitumor responses, and that PD-L1 immune checkpoint blockade can reverse acquired radioresistance.12-16 Radiotherapy might also allow effective use of immunotherapy against malignancies such as prostate cancer against which immunotherapies have not yet shown convincing efficacy, and more meaningful progression-free survival times among patients with brain metastases.17-21

Lung cancer is a focus of radioimmunotherapy research and development. There are currently at least 8 phase 1 and phase 2 clinical trials evaluating radiotherapy or chemoradiation plus a PD-1/PD-L1 immune checkpoint blockade agent, pembrolizumab or nivolumab, in patients with NSCLC.12

Findings from [ongoing] studies should cast muchneeded new light on toxicity risks. TOXICITIES Educating patients about the possible risks and toxic symptoms associated with radioimmunotherapy regimens will fall largely to oncology nurses, as will monitoring patients against the emergence of adverse events, which in some cases must be detected and managed quickly to avoid potentially life-threatening events. A 2017 systematic review of data from 49 clinical studies of concurrent stereotactic radiotherapy (SRT) and targeted therapies or immunotherapies, including 8 retrospective studies and case reports of ipilimumab radioimmunotherapy, found that the available evidence base suggests these treatments are well tolerated when deployed against brain metastases.4 However, it should be emphasized that most of the studies in this review described results for patients with brain metastases.4 The 6 retrospective studies of SRT plus concurrent CTLA-4 checkpoint blockade with ipilimumab in patients with melanoma brain metastases found that at median doses ranging from 14 to 60 Gy in 1 to 5 radiation fractions, SRT plus ipilimumab did not increase toxicity risks over ipilimumab immunotherapy

alone.4 Grade 3 toxicities included pruritus, hepatitis, diarrhea, pyrexia, nausea, fatigue, anorexia, skin reactions, endocrine reactions, and GI toxicities; one patient suffered grade 4 cardiopulmonary toxicity.4 Among reported toxicities were also grade 3 seizures and CNS hemorrhages attributable to SRT itself, rather than the combined radioimmunotherapy.4 Less is currently known about PD-1/ PD-L1 immune checkpoint blockade plus radiotherapy, although several clinical trials are now under way.4,10,12 Studies representing 27 patients receiving nivolumab plus SRT reported two cases of grade 3 cerebral edema and one case of grade 4 cerebral edema.4 As mentioned above, there are at least 8 phase 1 and 2 clinical trials under way for PD-1/ PD-L1-blockade radioimmunotherapy in patients with NSCLC.12 Findings from those studies, once reported, should cast much-needed new light on toxicity risks. The authors of the 2017 systematic review cautioned that even as concurrent SRT immunotherapy and targeted therapies become more widely used, little is yet known about the safety profiles of these combination regimens.4 They called for prospective registry databases to standardize and improve reporting of toxicities.4 ■ REFERENCES 1. Demaria S, Coleman CN, Formenti SC. Radiotherapy: changing the game in immunotherapy. Trends Cancer. 2016;2(6):286-294. 2. Van Limbergen EJ, De Ruysscher DK, Olivo Pimentel V, et al. Combining radiotherapy with immunotherapy: the past, the present and the future. Br J Radiol. 2017;90(1076):20170157. 3. Chajon E, Castelli J, Marsiglia H, De Crevoisier R. The synergistic effect of radiotherapy and immunotherapy: a promising but not simple partnership. Crit Rev Oncol Hematol. 2017;111:124-132. Continues on page 46

42 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

Navigating Complex Conversations

Ann J. Brady, MSN, RN-BC

Talking to the family of a loved one at a time of medical crisis can be the most daunting of conversations to have.

attended a conference recently to which I must give the credit for this mnemonic that prompts my memory when faced with difficult conversations: www — wish, worry, wonder.1 The End of Life Nursing Education Consortium (ELNEC) has its own version: the hope-worry statement, which is another great prompt. Both are terrific reminders, but www gives me more latitude in how to approach complicated communications with the families of patients no longer able to say what they want. CASE Talking to the family of a loved one at a time of medical crisis can be the most daunting of conversations to have, especially when their expectations do not match the reality of the situation. One such recent patient had stage IV colon cancer. His family barely had a chance to process the severity of his illness when things went south. In a relatively short period of time, he went from good

health to a diagnosis of advanced cancer to an adverse reaction to his treatment that resulted in respiratory complications and resultant dependence on a ventilator. He was in the ICU and looked terrible yet his family kept talking about what treatment was next once he got better. Early in the patient’s admission his family had a conversation with the oncologist where they asked when he could get more chemo. Of course, in their minds the only option was to keep fighting his cancer. The oncologist qualified his answer to the question, “Theoretically, in the best-case scenario, if he gets stronger we could try another chemo.” Although it was possible he could get stronger, it was, at best, a long shot. But what the family heard was “best-case scenario,” which for them translated to the likelihood he could get well enough to get more chemo. They struggled with the context — he had been healthy and strong just a few months before, therefore he had enough strength to get better. His sister even said, “After all, it isn’t like he’s been sick for a long time.” They hung on to the idea of more treatment because it meant he couldn’t possibly be as bad as everyone said he was. Never mind that his cancer was advanced, his response to chemo problematic, and in the meantime, after 11 days on a ventilator, he was getting weaker and weaker. Their hope for good news became their wish and their wish became the only reality they could consider. DISCUSSION How do we respond to families when the wished-for outcome is unlikely yet, at the same time, we want to preserve their hope? For those of us taking care of this patient, the clinical picture was obvious and dire. But

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 43

COMMUNICATION CHALLENGES

There are times when no communication strategy is able to break through the grief and denial. Wish, worry, and wonder may be rebuffed.

any explanation was met with the same response: If he can just get stronger he can get more chemo. We could easily characterize the family’s response as an obvious example of denial, but doing so only slaps a label on it. That label is like the label on a bottle, it only describes what is inside. Often, we focus on the label of denial, feeling it must represent a lack of information. The solution then becomes to give more information, which often backs families into a corner of resistance. They feel we do not hear them and we feel they do not listen to us. The patient’s family was determined to hold on to the possibility of him showing clinical improvement, even when it was explained as unlikely. In the ICU setting, the noise and pressure of ongoing adjustments to a patient’s condition can sometimes overpower the softer side of communication. So much is critical and time sensitive. Yet many times a softer approach accomplishes more. Instead of the goal being to break down loved ones’ denial, perhaps acknowledging it and revealing that there is in fact more than one outlook is better. This is where www can be helpful. Wish One place to start is to acknowledge the current circumstances. “I wish he wasn’t here in the ICU. I wish he’d been able to tolerate the chemo.” The wish statement recognized the difficulty of the situation without tearing it down. It allowed for loved ones to see that their hopes and concerns had been heard and in turn that we were not plotting against them. Worry “We are all hopeful that he can overcome this latest hurdle but I worry that he may not be able to. Have you had a conversation about what to do if he isn’t able to get better?” From a clinical standpoint, we knew the patient would not get better, probability outweighed possibility. Too much had already gone wrong, the trip back to better would be impossible regardless of the fight within him. But rather than going straight to the logic of explaining that, it was okay to acknowledge the hope. Too often the barrier of denial prevents us from finding a way around it. Admitting to being worried

about his condition helped the family see our concern was more than just clinical. Wonder Another approach is to ask, “I wonder what you see as happening next.” This question allows for both outcomes — getting better or continuing to deteriorate — and is more likely to be considered if I have allowed for the thread of hope families are clinging to. It is okay to direct it toward hope for wondering what is next. The question can nudge them further without the feeling of being pushed in one direction. It allows families to tell us what they envision and that allows for a direction we can follow. “I wonder what you imagine things will look like if what you hope for does not happen.” This does not take hope away, it allows for room to think about the unthinkable. Of course, there are times when no communication strategy is able to break through the grief and denial. Wish, worry, and wonder may be rebuffed. Our best efforts to connect with the family and help them see the reality of the situation did not materialize. In this case, the patient could not be weaned off the ventilator. In spite of being supported by the ventilator and 3 pressors, his blood pressure could not be maintained and he passed away in the ICU with family at his bedside. As hard as it is to be in a situation where we feel we can help, we have to accept that, unfortunately, patients may die in a way that we had hoped to avoid. Then www can be a way to reason and communicate to ourselves: I wish it had gone differently, I worry about the family, and I wonder if I would do things differently next time. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena California. REFERENCE 1. Byock I, Gonzalez M. Advanced Communication Training Workshop (ACT). Oral presentation at: Palliative Care, Pain Management and Whole Person Care Symposium; September 21-22, 2017; Fullerton, CA.

44 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

THE TOTAL PATIENT

Prosthetic Nipple Crowns Survivor’s Quest for Improved Breast Reconstruction Bette Weinstein Kaplan

number of postmastectomy options are available for women undergoing treatment for breast cancer. A patient might choose to do nothing and “go flat.” Or she might find breast reconstruction more cosmetically appealing. If she is not satisfied with the look of her reconstructed breast, she might choose to embellish it with a painterly tattoo of a flowering vine executed by a gifted artist such as David Allen. She might want just a simple nipple tattoo, perhaps. Of course, for a more anatomically accurate result she might choose nipple-conserving reconstruction, but that option is not always feasible for medical reasons. Enter breast cancer survivor Michelle Kolath-Arbel, whose disease was diagnosed in 2010. Her treatment included chemotherapy, a unilateral mastectomy, and reconstructive surgery. After 3 operations her breast was replaced, but it was bare — the nipple was missing. Every time she looked in the mirror she saw her breasts were different and was reminded of her breast cancer. She would need another surgery to create a nipple, but her doctors told her that her skin was too tight and sensitive. Another surgery was out of the question. Kolath-Arbel began looking for an alternative approach to nipple reconstruction. She explored prosthetic nipples, but all of the imitation nipples she found were hard plastic. She wanted a nipple that

looked and felt realistic. That is when she came up with the idea of making a prosthetic nipple from premium silicone that would give it a realistic look and feel. CRAFTING NIPPLES “LIKE CRAZY” “I studied the nipple-making process and crafted nipples like crazy!” explained Kolath-Arbel. “I wanted a nipple that would look and feel as close to my real one as possible. I wanted it to have a soft texture like my real nipple,

“I wanted a nipple that would look and feel as close to my real one as possible.” with thin edges that would blend to my skin. It took me a long time until I was satisfied with the results. Only then did I start selling them.” At that point Michelle founded her company, Pink Perfect (www.pink perfect.com), which produces realistic, ready-made and custom-made adhesive silicone nipples for survivors who have undergone unilateral or bilateral mastectomy. The prosthetics are handmade from the finest quality silicone, and thus are very close to the look and feel of real skin. They are waterproof and adhere to the breast with a medical-grade adhesive

that can last for days, so women can confidently wear them in the shower, swimming pool, or even swimming in the ocean. These silicone prosthetic nipples offer an alternative solution to nipple reconstruction surgery or nipple tattooing. There is no pain or surgery involved in the prosthetic nipple process. The prosthetics can last for years, and if the survivor is pleased with them, they can actually eliminate the need for more surgery and more expense. Furthermore, they are even reimbursable by insurance. Pink Perfect customers are both male and female and not only breast cancer survivors. Its customers include women whose nipples were damaged during breast reduction or augmentation surgery. The company also provides nipples for transgender men and women who are looking for a more feminine or masculine look. CUSTOMIZABLE CHOICES Pink Perfect has a catalog of its readymade nipples. These prosthetics are available in 3 of the most popular styles in 8 colors — from the lightest pink to the darkest brown — that match any shade of skin. Custom-made styles are available in an endless variety of size and color options. Kolath-Arbel said she can make any type of nipple of any shape and color, and has even had a request for one with a piercing. When a survivor is ready to order a

www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 45

THE TOTAL PATIENT custom-made nipple, the company sends her a simple kit for making an impression of her existing nipple. The customer also completes a short questionnaire on the details of the remaining nipple, and receives a color chart to choose from hundreds of colors. She can select different colors for the nipple and the areola, if that is what she wants. Making an impression of the remaining nipple is accomplished by applying a paste-like material that hardens in several minutes. The fine resolution of the material captures the nipple texture, including the bumps, and reproduces its overall look. The impression is sent with a photo, measurements, and the color

match from the chart. With these, Pink Perfect is able to create a nipple that is virtually identical to the remaining one. To increase the chance of receiving a perfect match, the customer receives 4 to 6 nipples with slight variations of color. The prosthetic nipples are shipped with an FDA-registered medical adhesive that has been fully tested with the prosthetic nipples during normal day-to-day activities. The adhesive is waterproof and can hold the prosthetic nipple for about a week (depending on skin type and moisture level). The postmastectomy patient can usually start wearing her new prosthetic nipple 3 weeks after surgery, once the area has healed completely.

Ref lecting on her life-changing work, this medical artist says, “In a way I cannot put breast cancer behind me because I’m in touch with so many women. “Some passed away, some became metastatic, and my heart breaks every time I hear this. But on the other hand, I talk to many brave and powerful women that I am inspired by in so many ways. I am the one who helps them to be able to feel sexy again … or to simply get undressed in front of their mates or kids. I feel very privileged.” ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

Radiation & Your Patient

Complete response of mediastinal clear cell

fractionated radiotherapy can be overcome

Continued from page 42

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46 ONCOLOGY NURSE ADVISOR • NOVEMBER/DECEMBER 2017 • www.OncologyNurseAdvisor.com

s patients with breast cancer near the end of their active treatment phase, they often anticipate that the final chemotherapy or radiation session will bring a mixture of joy, relief, and a sense of closure. After months or longer of appointments, tests, medication, and doctors, women eagerly await the day when they will reach the “light at the end of the tunnel.” But the transition into posttreatment life can often be more emotionally fraught than initially imagined. Rather than a clear demarcation between their experience and the start of their new normal, many patients describe the end of treatment as a sense of “being in limbo” as they process what they just experienced. This new phase can bring a wide range of feelings to the forefront, many of which are confusing to the woman whose internal experience feels so different from what was expected. However, the challenges that arise as patients navigate the transition into survivorship are often not addressed. Clinicians prepared for this new stage at the beginning of posttreatment can help patients greatly with timely education, support, and interventions. Treatment and survivorship are not fixed points on a linear timeline. To better understand what patients may experience following treatment, cancer should be looked at as an ongoing, ever-evolving condition rather than a single event with a defined end. Discussions on the stages of cancer can impact patients’ expectations of what

Navigating the Breast Cancer Posttreatment Transition Stacy Lewis, LMSW, ACHP-SW

“done with treatment” will look like. Closure is not immediate, which can be at odds with the internal or external expectations. Patients do not immediately absorb the reality of their medical situation and all the changes they have been through into their sense of self and social functioning.1

THE NEXT UNKNOWN Patients with breast cancer transitioning into survivorship may also be impacted by cultural and media representations of what a breast cancer survivor looks like. Some women strongly identify with the image of the breast cancer warrior or pink power and find it empowering. Others may not. One woman described frustration at what she viewed as the limited understanding of breast cancer survivorship: “They think now that treatment is done, I’ve wrapped up the experience in a neat pink bow and can move on.” Friends and family may be surprised to find that the patient is dealing with conflicting emotions now that the “hard part” is over. At the same time, the support network she had during treatment may wane. The need for support does not go away after treatment, but articulating to friends and family what is needed as a survivor is often difficult. Patients may verbalize that they don’t want to be a continued burden on a support network that has done so much, which in turn might bring up shame and guilt that they should be coping better than they are. For many women, the loss of the oncology care team and the transition to fewer medical appointments can be a significant challenge as treatment ends. Often women form strong bonds with their oncology care team, and many women report a sense of safety in the regimented medical oncology routine. Patients in treatment may find comfort in knowing they are doing something, so as treatment stops, anxiety about recurrence often increases significantly. Posttreatment patients wonder what symptoms they should look out for, how to communicate

The loss of the oncology care team and the transition to fewer medical appointments can be a significant challenge. www.OncologyNurseAdvisor.com • NOVEMBER/DECEMBER 2017 • ONCOLOGY NURSE ADVISOR 47

FROM

FROM with their medical team now, and how to manage their fears of disease recurrence. During this uncertainty, the patient is often concurrently navigating re-entry into the workforce and resumption of their familial roles. She may need to go back to work before she feels ready to due to financial or job-security concerns. Family members and caregivers who have taken on increased responsibilities (such as childcare) often anticipate their return to normal, too, as they often have to return to jobs or previous responsibilities as well. Patients verbalize a sense of internalized pressure to get back to functioning at full speed, while regaining the physical/ emotional energy needed may take longer than anticipated. SUGGESTIONS FOR CLINICIANS Be proactive as a patient’s treatment is winding down Outline what the survi-

vor can expect in terms of future appointments, tests, and communication with the oncology team. Provide a survivorship care plan that includes details about the treatment she received and who she can reach out to for future questions or concerns. This can lessen the anxiety around losing the oncology team. Be mindful of the language you use to discuss survivorship Acknowledge

that this is not an end point but an ongoing state. Each patient will define what

survivorship and ending treatment means to her. Words and phrases such as survivor, warrior, and new normal may be emotionally charged. One woman may feel empowered by certain terminology, whereas another may feel it does not represent her experience or feelings. Acknowledge that the posttreatment transition may have challenges

Be mindful of the patient’s ability to tolerate sharing of information based on where they are in their treatment. For example, my online breast cancer support group started a topic folder titled “Post-Treatment Stage and Resources.” It provided a safe space for women navigating this transition to speak openly about their fears, and women earlier in the treatment continuum can choose not to approach that particular topic if they are not ready. Creating space (during appointments, in support groups, etc) for these discussions gives survivors permission to have these feelings, thereby normalizing them. Keep in mind the patient’s financial and logistical realities Offer ways

to help ease the transition back into work and familial obligations and provide referrals to organizations such as Cancer and Careers (www.cancerand careers.org) and Cancer Legal Resource Center (www.cancerlegalresources. org). They provide advice on resume

reviews, cancer-related workplace laws, and communicating with employers. Explore with the survivor a plan that may make workplace re-entry more manageable, such as starting with fewer days/hours and building up. Include the family and support network Involving those close to the patient

in psychoeducation about the posttreatment transition can help normalize and manage expectations. Facilitate discussions between patients and their support systems about the ongoing practical and emotional needs and how the support network can be involved. Offer targeted support to the posttreatment population Support groups

(either face-to-face, online, or via telephone) and individual counseling can offer space for the patient to verbalize her experience, process feelings, and receive support and validation. Organizing family meetings in which all parties can safely express their fears, concerns, and hopes also can be helpful. ■ Stacy Lewis is the Women’s Cancers Program coordinator at CancerCare. REFERENCE 1. Christ G, Messner C, Behar L, eds. Handbook of Oncology Social Work: Psychosocial Care for People With Cancer. New York, NY: Oxford University Press; 2015.

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ASK A PHARMACIST 3D rendering of rucaparib molecule

End of ESA APPRISE; PARP Inhibitors and Leukemia What happened to the ESA APPRISE program? Why were these changes made?

patients with cancer. Specifically, the program was concerned with ensuring that patients and providers were aware of the risks inherent with using these agents and that their use in this population was in accordance with current clinical guidelines. In April 2017, the Food and Drug Administration (FDA) ended the ESA APPRISE REMS program after determining that healthcare providers understood the previously mentioned risks and were prescribing these agents appropriately according to current clinical guidelines.1 This action was due to changes in both the prescribing information and the Centers for Medicare and Medicaid (CMS) reimbursement guidelines for ESAs. As such, the FDA deemed that the certifications and other requirements of the ESA APPRISE program provided no additional educational benefit. However, a lthoug h the ESA APPRISE program is no longer required when using ESAs in patients with cancer, the risks associated with these agents remains the same.

rucaparib (Rubraca), and niraparib (Zejula). Warnings about MDS or AML are listed in the prescribing information for the above the PARP inhibitors currently used in the United States. BRCA is involved with repair of DNA damage, and defects in DNA repair may increase the risk of developing MDS or AML. Because of this, MDS or AML are more of a concern in patients with BRCA mutations. MDS or AML has been reported in 0.5% to 2% of patients taking the various approved PARP inhibitors. Reports indicate that the patients had received prior treatment with platinumbased chemotherapy or other DNAdamaging agents, and most of the cases of MDS and AML were reported in patients with BRCA mutations. Regular monthly monitoring of complete blood counts (CBC) are recommended for patients being treated with PARP inhibitors. Patients with prolonged hematologic abnormalities should undergo further evaluation. If the patient develops MDS or AML, the PARP inhibitor should be discontinued. ■

— Name withheld on request

What is the concern behind PARP inhibitors and leukemia?

REFERENCE

The erythropoiesis stimulating agent (ESA) APPRISE program was initiated in 2010 for the ESAs on the market in the United States: epoetin alfa (Epogen, Procrit) and darbepoetin alfa (Aranesp). ESA APPRISE was a risk evaluation and mitigation strategy (REMS) program created to ensure that the benefits outweighed the risks when ESAs are used to minimize red blood cell transfusions in patients with cancer and chemotherapy-induced anemia. The specif ic risks this program addressed included shortened overall survival and increased likelihood of tumor progression and recurrence in

— Name withheld on request

1. Information on erythropoiesis-stimulating agents (ESA) epoetin alfa (marketed as

Myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) have been reported in patients receiving poly(ADP-ribose) polymerase (PARP) inhibitors such as olaparib (Lynparza),

Procrit, Epogen), darbepoietin alfa (marketed as Aranesp). U.S. Food and Drug Administration; https://www.fda.gov/Drugs/ DrugSafety/ucm109375.htm. Last updated March 13, 2017. Accessed November 1, 2017.

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

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