ONA September/October 2014 by Haymarket Media

ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014

September/October 2014

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FREE CONTINUING EDUCATION INSIDE Using guideline adherence to manage CINV effectively, PAGE 20

RADIATION & YOUR PATIENT

High-dose-rate brachytherapy

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NURSE NAVIGATION

Chaplaincy: Integrating nonclinicians into the cancer care continuum A novel study on clinicians’ perceptions of the role of the chaplain reveals that nurses have a better understanding of what chaplains do.

THE TOTAL PATIENT

A new concept in health care facility design improves patient outcomes

COMMUNICATION CHALLENGES

Overcoming a language barrier with a patient’s mother

REFLECTIONS

Lessons from a nursing mission to Africa VOLUME 5, NUMBER 5

ASK A PHARMACIST

Reconstituting nab-paclitaxel Managing venous irritation

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Oncology Nurse Advisor (ISSN 2154-350X), September/October 2014, Volume 5, Number 5. Published 6 times annually by Haymarket Media Inc, 114 West 26th Street, 4th Floor, New York, NY 10001. Oncology Nurse Advisor is available for single copy purchases at the following rates. Price per copy: USA $20; Foreign $30. To order call (800) 558-1703. For advertising sales, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

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

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

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 • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 5

CONTENTS

September/October 2014

IN THE NEWS • ANA takes a stand on nurse fatigue • Dasatinib has promise for other cancers • Navigator Notes: Facing prostate cancer—but not alone • Heeding genetic keys to therapy resistance in glioblastoma

ONCOLOGY NURSE ADVISOR FORUM • Standard of care for delivering bisphosphonates • Indications for pazopanib • New G-CSF approved in Europe, in clinical trials in the US • Vitamin B can ease peripheral neuropathy symptoms • Efficacy of half-strength chemotherapy

CONTINUING EDUCATION Using guideline adherence to manage CINV effectively

Una T. Hopkins, DNP; Diana Donovan, MSN, NP

FEATURE Navigating nonclinical patient care: A review of chaplaincy David McDaniel

STAT CONSULT Trastuzumab (Herceptin)

RADIATION & YOUR PATIENT High-dose-rate brachytherapy: An option for prostate cancer Bryant Furlow

52 FIND US ON

COMMUNICATION CHALLENGES Speaking without words Ann J. Brady, MSN, RN-BC

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

43 45

Answer the ONA poll question

THE ONA INTERVIEW Educating men about prostate cancer FROM CANCERCARE Animal assisted therapy enhances cancer care Erin Columbus, LCSW

ISSUES IN CANCER SURVIVORSHIP Camp Dream Street provides a summertime staple for kids with cancer Bette Weinstein Kaplan

THE TOTAL PATIENT Evidence-based design: A new concept in health care facilities that puts the focus on patients Bette Weinstein Kaplan

Subscribe to ONA newsletters Stay current with daily news reports and special series from key oncology conferences on our Web site, sign up for our e-newsletters at OncologyNurseAdvisor.com/subscribe. Earn CE credits

REFLECTIONS Out of Africa Maureen Timony, RN

ONA asks… Answer our poll question and compare your opinions with those of your colleagues on key nursing issues at OncologyNurseAdvisor.com

ASK A PHARMACIST Reconstituting nab-paclitaxel; managing irritation from fosaprepitant Lisa A. Thompson, PharmD, BCOP

•

FEATURE ARTICLES • Prior diagnosis of depression worsens outcomes in prostate cancer

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

Lauren Evoy Davis

• Now what? Aiding patients in planning for cancer survival Kathy Boltz, PhD

ISSUES IN CANCER SURVIVORSHIP • Chemoprotective effects of coffee Bette Weinstein Kaplan

ON THE

WEB

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 7

IN THE NEWS

ANA takes a stand on nurse fatigue

are expected as part of the new policy statement, which Barry reports has stronger language for both nurses and employers regarding hours worked in a 7-day period. This stronger language will point out and disapprove of excessive hours logged at second and third jobs, which many nurses have, as well as some aspects of how nurses use their own free time, said Barry. In November 2013, the ANA made it clear that it was going after a change in employer oversight of nurse time off. Barry listed things the ANA wanted considered when deciding if a nurse is too fatigued to work a shift safely. The list included

This position statement also wants stressors from outside the workplace considered when determining nurse fatigue.

The American Nurses Association’s current position for nurses when it comes to avoiding fatigue is essentially “know when you need to stop.” 10 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

things outside the workplace and beyond the traditional control of health care employers, things such as overtime, personal anxiety, learning new technology, travel to nursing assignments, night shift and day shift ratios, multiple jobs, physical fatigue, and other daily stresses. Now the nurse fatigue position statement is stuck as a draft in the steering committee where it has been for the last 6 months. Half a year after the ANA’s Professional Issues Panel (PIP) completed its deliberations and the 20-day public comment period for the PIP’s draft (which ended on February 10, 2014), any new detail of the fatigue position statement is a closely guarded secret. “ANA cannot speak to the content of the document until it is approved and available for public release,” said Jamie Dawson, the senior policy analyst on occupational safety and health at the American Nurses Association. Until the ANA publishes the final document, its current position for employers of nurses is to provide safe working hours and a pay scale that prevents the temptation for nurses to moonlight. The ANA’s current position for nurses when it comes to avoiding fatigue is essentially “know when you need to stop.” This is an excerpt from “American Nurses Association (ANA) breakthrough statement struggles over hours worked.” To read the article in its entirety, go to OncologyNurseAdvisor.com/ ANA-position-statement. ■

AS THE American Nurses Association (ANA) prepares to go public with its first position statement on nurse fatigue in almost 10 years, the landmark document appears to be leaning toward recommendations to limit the total number of hours nurses can work during a week, no matter where that might be. The ANA will not disclose the exact details of its groundbreaking fatigue policy statement, which is the first from the organization to include recommendations for nurses and employers in the same document. Until now the ANA traditionally produced separate position statements for employers (hospitals and clinics) if deemed necessary. Marie-Elena Barry, RN, senior nursing policy and practice analyst for the ANA in Silver Springs, Maryland, told Oncology Nurse Advisor that merely asking nurses to stay alert when they worked was no longer enough to prevent fatigue-related accidents. She said the ANA wants to give employers a greater role in combating nurse fatigue and thus “believe that the statement should recognize that nurses and employers work together.” Recommendations to cap the number of hours worked by nurses within any given week

Dasatinib has promise for other cancers THE LEUKEMIA drug dasatinib shows promise as a treatment for skin, breast, and several other cancers. Dasatinib fights leukemia by checking the uncontrolled growth of cancer cells. But when used against other cancer cells, researchers found the drug causes the cells to clump together, thus preventing them from migrating. Mitchell Denning, PhD, and colleagues at Loyola University Chicago Stritch School of Medicine, in Illinois, discovered the molecular mechanism behind this cell-cell adhesion, as reported in a study published in Molecular Carcinogenesis (2014; doi:10.1002/ mc.22190). Dasatinib (Sprycel) is approved for certain types of leukemia. It targets the protein BCR-ABL which fuels cancer cell growth. BCR-ABL is similar to the protein Fyn, found in other malignancies, including breast, brain, pancreatic, skin, and head-and-neck cancers. Fyn is associated with cell-cell adhesion and cell migration. Applying dasatinib to cancer cells in the laboratory caused the cells to clump together, and also prevented cell migration. Although dasatinib did not eliminate Fyn, it inhibited the protein’s activity. Clinical trials are underway to test dasatinib in patients with melanoma, prostate cancer, pancreatic cancer, endometrial cancer, GIST, ovarian cancer, multiple myeloma, Hodgkin lymphoma, and ALL. ■

Navigator Notes Facing prostate cancer—but not alone Frank dela Rama, RN, MS, AOCNS Shock. Numbness. Slow motion. Weak in the knees. “Is it a dream?” These are just a few descriptors of the initial mindset when men first receive word that they have prostate cancer … devastating news that leads to a myriad of questions about what to do next. As a nurse navigator, other than their diagnosing physician, I am the first point of contact soon after this news is received. In my meetings with these men and their families, a crash course in prostate cancer biology is soon followed by in-depth discussions of the options for cancer treatment, as well as what to expect with each proposed care path. There is rarely a clear cut choice, and many times surgery and radiation offer similar expected outcomes, in effect giving men too many choices … a set of choices they probably would have preferred to avoid altogether. Prostate cancer is a male cancer, but it affects the entire family unit, from wives and partners to children and siblings. The clinical side effects of treatment unfortunately are often intertwined with very personal and intimate issues. Since we identify prostate cancer at an early stage most of the time, these men are also usually very healthy otherwise. (“I eat right, exercise regularly, and now I have cancer?!”) The good news is prostate cancer is very well managed … not a “death sentence” but considered more in line with diabetes or heart disease, a chronic condition that we can monitor and treat with many medical tools. The best case scenarios are those men who have definitive treatment, eventually needing only a yearly

PSA blood test as they progress years even decades after treatment. Even for those men who need additional treatment for prostate cancer that comes back, we have treatment options that can also keep the cancer in check for months to many years. I have had the privilege of working with hundreds of men and their families, in an effort to guide them through this decision-making process. Serving as teacher, advocate, confidant, and any other roles as called for (eg, sounding board, referee, buddy, etc), I aim to make the tortuous journey from diagnosis through treatment as smooth as possible. By contributing to Oncology Nurse Advisor, I hope to use my expertise, plus knowledge culled from the shared experiences from all the men and families I have encountered, to provide some useful insights into prostate cancer, from screening and prevention, to diagnosis and treatment, and on into survivorship or the “new normal.” As oncology nurses, we all serve to some degree as navigators for our patients. I hope that this will be yet another forum to share ideas and stories about how to best impact the lives of patients and families dealing with cancer. Please feel free to share your feedback and comments, so we can address the issues most pertinent in our day-to-day practice in cancer care. ■ Frank dela Rama is a clinical nurse specialist, oncology/genomics, and prostate cancer navigator at Palo Alto Medical Foundation in Palo Alto, California.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 11

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

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

» Safety was evaluated in 3 Phase III clinical trials1

Indication

Important Safety Information (continued)

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

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

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

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

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

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

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

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

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

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

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

» Safety was evaluated in 3 Phase III clinical trials1

Indication

Important Safety Information (continued)

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

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

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

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

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

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

IN THE NEWS

FDA Update The FDA granted accelerated approval to pembrolizumab (Keytruda) for the treatment of patients with unresectable or metastatic melanoma and disease progression following ipilimumab and, if BRAF V600 positive, a BRAF inhibitor. Pembrolizumab is a monoclonal antibody that binds to the PD-1 receptor and blocks its interaction with PD-L1 and PD-L2, thereby releasing PD-1 pathwaymediated inhibition of the immune response including antitumor immune response. The recommended dose is 2 mg/kg IV infusion over 30 minutes every 3 weeks. A new FDA-approved indication for enzalutamide (Xtandi) capsules is for metastatic castration-resistant prostate cancer (CRPC). Enzalutamide was initially approved for use in patients with metastatic CRPC who previously received docetaxel. The new indication approves the agent for use in men with metastatic CRPC who have not received chemotherapy. Bevacizumab (Avastin) is now FDA-approved for the treatment of persistent, recurrent or late-stage (metastatic) cervical cancer. The new indication for cervical cancer is approved for use in combination with paclitaxel and cisplatin or in combination with paclitaxel and topotecan. ■

Heeding genetic keys to therapy resistance in glioblastoma RESEARCHERS HAVE found one of the keys to why certain glioblastomas are resistant to drug therapy. The answer lies not in the DNA sequence of the tumor, but in its epigenetic signature. “There is a growing interest to guide cancer therapy by sequencing the DNA of the cancer cell,” said Clark Chen, MD, PhD, vice-chairman of Research and Academic Development, University of California (UC), San Diego School of Medicine, Division of Neurosurgery, and the principal investigator of the study, published in Oncotarget (2014;5[6]:1515-1525). “Our study demonstrates that the sensitivity of glioblastoma to a drug is influenced not only by the content of its DNA sequences, but also by how the DNA sequences are organized and interpreted by the cell.” Chen’s team used comparative gene signature analysis to study the genetic profiles of tumor specimens collected from approximately

ONA ASKS …

Because EGFR is turned off in these glioblastomas, they become insensitive to drugs designed to inhibit EGFR signaling.

900 glioblastomas. The method allows investigators to discriminate whether specific cellular processes are turned on or turned off. One of these cellular processes involves epidermal growth factor receptor (EGFR). The study revealed that EGFR signaling is suppressed in a subset of glioblastomas. Importantly, this suppression is not the result of altered DNA sequences or mutations. Instead, EGFR is turned off as a result of how the DNA encoding the EGFR gene is organized in the cancer cell. This form of regulation is termed epigenetic. Because EGFR is turned off in these glioblastomas, they become insensitive to drugs designed to inhibit EGFR signaling. “Our research suggests that the selection of appropriate therapies for our brain tumor patients will require a meaningful synthesis of genetic and epigenetic information derived from the cancer cell,” said co-first author Zachary J. Taich. ■

YES

A recent study on nursing practice revealed that an estimated 17.5% of newly licensed nurses leave their first nursing job within 1 year, and 1 in 3 leave within 2 years. How long did you work at your first nursing job? Go online to answer our poll question. We’ll publish the results and a new question in the next issue. … AND YOU ANSWERED In the last issue we asked if you are up-to-date with the cancer screenings appropriate for you.

91% Yes, I am up-to-date 9% No, I’m better at caring for others than myself

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 15

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

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

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

QUESTIONS & ANSWERS STANDARD OF CARE FOR DELIVERING BISPHOSPHONATES In the past, we have given patients with breast cancer adjuvant bisphosphonates orally for life, especially if the patient is on hormonal modulation therapy (ie, aromatase inhibitors); however, I have seen several patients with femoral fractures. As a result, I tend to give the patient a break after 5 years if her bone mineral density (BMD) has improved and her T score is higher than –2.0. I also have the same issue with patients with metastatic disease. In the past, we gave them bisphosphonates (zoledronic acid [Zometa], pamidronate disodium [Aredia], or denosumab [Xgeva]) monthly for 2 years. After seeing several cases of osteonecrosis of the jaw (ONJ) and large bone fractures, we now hesitate to push so hard. If a patient’s bone pain is improved, we tend to push dosing out to every 2 months after 6 months of therapy. What protocol would you recommend in these settings? —Susan Siemsen, PA-C Guidelines recommend that patients use IV bisphosphonates, such as zoledronic acid (Zometa), due to results from a recent clinical trial that suggested this bisphosphonate may extend survival. In addition, they recommend that physicians administer standard doses of bisphosphonates every 3 to 4 weeks. How long bisphosphonates should be used is still unclear. And currently, there is no randomized data on bisphosphonate use for more than 2 years. As a result, physicians should assess a patient’s risk and benefit of using bisphosphonate treatment after 2 years. There is no standard for the application of a more attenuated schedule as opposed to complete discontinuation. Researchers have speculated that long-term use of bisphosphonates increases the risk of developing ONJ, a rare but serious side effect of bisphosphonate use in which there is a loss of blood supply to the jaw, causing jawbone tissue to die. To prevent ONJ, patients treated with bisphosphonates should maintain good dental hygiene and should stop bisphosphonate treatment for 90 days before and after invasive dental procedures. Fractures of the upper leg and in the feet have also been reported after long-term use of bisphosphonates; however, this effect is rare. The guidelines also recommend that patients make sure to get enough vitamin D and calcium, nutrients essential for strong and healthy bones. This is especially a concern for patients with myeloma because 60% of these patients are vitamin D- and calcium-deficient. Calcium supplementation should be used cautiously for patients with kidney problems. Denosumab (Xgeva), a human RANKL compound, may be preferred for patients with renal insufficiency, but the ONJ risk remains and denosumab is not indicated for myeloma. As far as adjusting plans based on repeat bone density studies, this is not supported by the literature as even those patients who lose bone density seem to benefit. —Donald R. Fleming, MD Continues on page 18

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

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

16 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

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ONCOLOGY NURSE ADVISOR FORUM [Vitamin B] can help maintain proper functioning of the nervous system because it encourages normal nerve cell communication. Dietary sources of this vitamin include potatoes, bananas, peanut butter, salmon, and chicken. INDICATIONS FOR PAZOPANIB Is pazopanib (Votrient) approved for the treatment of leiomyosarcoma? I believe it is approved for advanced renal cell carcinoma. —Elizabeth Greenberg, RN, ANP

VITAMIN B CAN EASE PERIPHERAL NEUROPATHY SYMPTOMS Any truth to the theory that vitamin B6 helps with chemotherapy-induced neuropathy? —Name withheld on request

Pazopanib (Votient) is an antineoplastic agent or tyrosine kinase inhibitor (TKI) that is currently approved for renal cell carcinoma, administered as an oral dose of 800 mg once daily. It is also indicated for advanced refractory soft tissue sarcoma (STS), administered in the same dose and frequency. Leiomyosarcoma is a soft tissue sarcoma that arises from smooth muscle cells. Off-label or unlabeled use reported was for the treatment of advanced differentiated thyroid cancer. —Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/ PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS

Vitamin B6 (pyridoxine) is a B vitamin known to be important for nerve health. In addition, it can help maintain proper functioning of the nervous system because it encourages normal nerve cell communication. Dietary sources of this vitamin include potatoes, bananas, sunflower seeds, lima beans, peanut butter, salmon, and chicken. According to the Mayo Clinic, vitamin B6 injections and vitamin B1/B6 injections can be used to reduce the risk and aid with the symptoms of peripheral neuropathy. —Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS

NEW G-CSF APPROVED IN EUROPE, IN CLINICAL TRIALS IN THE US I am hearing there is a new G-CSF coming out on the market produced by Teva. What can you tell us about this product? —Lauren Covely, RN, BSN, OCN In February 2014, Teva UK Limited announced the launch of lipegfilgrastim (Lonquex). Lipegfilgrastim is a long-acting recombinant granulocyte colony-stimulating factor (G-CSF). Its active ingredient is a novel glyco-pegylated filgrastim molecule. Lipegfilgrastim is indicated for use in reducing the duration of neutropenia and decreasing the incidence of febrile neutropenia in adult patients who are treated with cytotoxic chemotherapy for maglignancy. Lipegfilgrastim has undergone a full clinical development program as part of the assessment process for use in patients undergoing chemotherapy. The European Medicines Agency (EMA) recommended approval of lipegfilgrastim in July 2013. —Abimbola Farinde, PharmD, MS, BCPP, CGP, LCDC, PM/PRC, FASCP, FACA, FNAP, Rsci, ARSPharmS A comparison study of lipeg filgrastim and peg filgrastim is listed in ClinicalTrials.gov as currently recruiting participants (http:// clinicaltrials.gov/show/NCT02044276). The primary objective of the study is to demonstrate noninferiority of lipeg filgrastim to peg filgrastim for the duration of severe neutropenia in the first cycle of chemotherapy. —The Editors

EFFICACY OF HALF-STRENGTH CHEMOTHERAPY Is there any benefit to half-strength chemotherapy given to patients experiencing side effects from the drug or due to decreased functional status? It seems that diluting the chemotherapy is not recommended because of cell tolerance and developing resistance to the chemotherapy. I see many elderly patients receive half-strength chemotherapy, and it does not seem to make them sicker. What are some thoughts on this strategy? —Name withheld on request Most evidence suggests that the relative effectiveness and safety of chemotherapy is similar for patients who are older than 65 years vs those who are younger. When differences are reported, treatment effects are more often worse among the elderly. Data suggest that without other reasons for withholding treatment, elderly patients should receive chemotherapy the same as nonelderly patients. Reducing the number and/or dose of cancer therapy would typically trade reduction in toxicity for reduction in efficacy. This may be especially relevant where the goal is cure vs palliation. In general, if a caregiver feels the patient should not receive full doses of therapy, then best supportive care should be taken into strong consideration. I often see no harm in starting low and dose escalating to tolerance when the goal is palliation, but to settle on a low and possibly nonefficacious dose would not be the best route to follow. —Donald R. Fleming, MD

18 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

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CONTINUING EDUCATION Disclosure of Conflicts of Interest Medical Education Resources ensures balance, independence, objectivity, and scientific rigor in all our educational programs. In accordance with this policy, MER identifies conflicts of interest with its instructors, content managers, and other individuals who are in a position to control the content of an activity. Conflicts are resolved by MER to ensure that all scientific research referred to, reported, or used in a continuing education activity conforms to the generally accepted standards of experimental design, data collection, and analysis. MER is committed to providing its learners with high-quality activities that promote improvements or quality in health care and not the business interest of a commercial interest. The faculty reported the following financial relationships with commercial interests whose products or services may be mentioned in this activity: Name of faculty

Reported Financial Relationship

Una T. Hopkins, DNP Member of Speakers’ Bureau at Esai Inc. Diana Donovan, MSN, NP

No financial relationships to disclose

Jennifer Steeber

Editorial serices provided by Esai Inc.

The content managers reported the following financial relationships with commercial interests whose products or services may be mentioned in this activity: Name of Content Manager

Reported Financial Relationship

Joyce Pagán

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Disclaimer The content and views presented in this educational activity are those of the authors and do not necessarily reflect those of Medical Education Resources or Haymarket Media. The authors have disclosed if there is any discussion of published and/or investigational uses of agents that are not indicated by the FDA in their presentations. The opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of Medical Education Resources or Haymarket Media. Before prescribing any medicine, primary references and full prescribing information should be consulted. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. The information presented in this activity is not meant to serve as a guideline for patient management.

EDUCATIONAL OBJECTIVES After participating in this activity, clinicians should be better able to • Define the types of chemotherapy-induced nausea and vomiting (CINV) • Identify the challenges to effective management of CINV • List prophylactic regimens for high-, moderate-, and low-emetogenic chemotherapies

STATEMENT OF NEED/PROGRAM OVERVIEW Chemotherapy-induced nausea and vomiting (CINV) is a significant side effect of cancer treatment that many patients experience. Barriers to effective prophylactic care and treatment are patient acceptance of CINV episodes as part of treatment and consequent failure to report episodes, and lack of risk assessment. This activity will describe the types of CINV, list risk factors to assess patients for, and list effective antiemetic regimens based on the emetogenicity of various common chemotherapy agents. FACULTY Una T. Hopkins, DNP Administrative Director, White Plains Cancer Center White Plains, NY Diana Donovan, MSN, NP Dubin Breast Center, Mount Sinai Hospital New York, NY LEARNING GOAL/PURPOSE To know the types of chemotherapy-induced nausea and vomiting patients may experience and how best to manage this adverse effect. NURSING CREDIT Medical Education Resources is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This CE activity provides 1 contact hour of continuing nursing education. Medical Education Resources is a provider of continuing nursing education by the California Board of Registered Nursing, Provider #CEP 12299, for 1 contact hour. METHOD OF PARTICIPATION There are no fees for participating in and receiving credit for this activity. During the period October 2014 through October 2015, participants must 1) read the learning objectives and faculty disclosures, 2) study the educational activity, 3) complete the posttest by selecting the best answer to each question on the posttest, 4) complete the evaluation form, and 5) continue to next section to claim credits and view your certificate. A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better. Statements of credit are available at the conclusion of the activity. MEDIA

Journal article and Web site (myCME.com; OncologyNurseAdvisor.com) Co-provided by Medical Education Resources and Haymarket Media Inc. To contact this co-provider, please email info@cmepartner.org

20 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

TARGET AUDIENCE

PROGRAM INFORMATION

• This activity has been designed to meet the educational needs of registered nurses and nurse practitioners involved in the management of patients with cancer.

• Estimated time to complete this activity: 1 hour • Release date: October 2014 • Expiration date: October 2015

Using guideline adherence to manage CINV effectively Guidelines for managing chemotherapy-induced nausea and vomiting direct management toward risk assessment and prophylactic antiemetics.

Illustration of 5-HT3 GABA receptors and its antagonists binding to them (background) and a cross section of the brain stem showing the vomiting center (green).

UNA T. HOPKINS, DNP; DIANA DONOVAN, MSN, NP

hemotherapy-induced nausea and vomiting (CINV) is an underappreciated challenge in the treatment of oncology patients.1 CINV is often under-reported because patients perceive nausea and vomiting as expected side effects, and therefore may not report incidents to their oncology care providers. In addition, some types of CINV may not be captured in infusion records or with a 24-hour callback system. Oncology nurses are at the front lines in the management of CINV, and using guideline recommendations, they can work collaboratively with other health care professionals to advocate for the highest quality of care.2,3,4 Recommendations in the treatment guidelines have been shown to enhance patient care, yet adherence to these guidelines is often poor.3 This review of the evidencebased recommendations can help oncology nurses identify gaps in their understanding of this effect and improve outcomes for their patients.2 Continues on page 22

TO TAKE THE POST-TEST FOR THIS CE ACTIVITY

and apply for 1.0 contact hours, please go to myCME.com/CEOCT2014

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 21

CONTINUING EDUCATION | CINV guidelines AN OVERVIEW OF CINV CINV is classified as acute, delayed, anticipatory, breakthrough, or refractory.5,6 Acute CINV occurs less than 24 hours after initial chemotherapy administration and generally peaks after 5 to 6 hours.6,7 Delayed CINV generally occurs 24 hours or more after a treatment, peaks approximately 48 to 72 hours after chemotherapy, and may last as long as 5 to 7 days.6,7 Anticipatory nausea and vomiting occurs before a cycle of chemotherapy due to a poor response in a previous cycle, and is triggered by cues associated with that previous experience.6,7 Breakthrough CINV is that which occurs despite the best possible prophylactic treatment, and refractory CINV occurs when all previous preventive and rescue treatments have failed in prior cycles.6,7

Delayed CINV may be more common than acute CINV as it is less likely to be reported, and therefore also less likely to be treated effectively. The impact of CINV is borne by patients as well as by the health care system. Both nausea and vomiting have been shown to adversely affect a patient’s quality of life8,9,10; delayed CINV, in particular, may have a greater impact than acute CINV.10 Health service utilization and medical costs are also increased.11,12 However, one of the most concerning aspects of CINV is that patients may delay or stop chemotherapy, thus compromising quality of care and reducing the likelihood of treatment success.3,9 Particularly in cases of therapies with curative intent, changes in the planned courses of treatment can have serious consequences such as lower survival rates.9 Mechanism of action In brief, chemotherapeutic agents can damage the enterochromaffin cells of the gastrointestinal tract, releasing serotonin that binds to 5-hydroxytryptamine (5-HT3) receptors.7 This binding stimulates vagal nerve afferents that either initiate emesis directly resulting in acute CINV, or sensitize the vagus nerve to other substances (such as substance P), which can lead to delayed CINV.7 Therefore, acute CINV is thought to be more highly associated with serotoninergic pathways, whereas substance P may be more involved in delayed CINV.3 Recommendations for antiemetic therapy are based on the emetogenicity of the chemotherapy being administered.6 An agent is considered a highly emetogenic chemotherapy (HEC) if greater than 90% of patients are expected to experience emetic episodes if no prophylactic antiemetics are

administered. It is a moderately emetogenic chemotherapy (MEC) if 30% to 90% of patients are expected to experience emetic episodes if no prophylactic antiemetics are administered. Low and minimally emetogenic chemotherapies (LECs) are expected to cause emetic episodes in 10% to 30% and less than 10% of patients, respectively, if no prophylactic antiemetics are administered. MANAGING CINV: PRACTICAL NURSING ISSUES Guideline-based treatment can often prevent nausea and vomiting, which improves both patient satisfaction and caregivers’ experiences.4 The oncology nurse’s role can include evaluating patient risk factors for CINV and communicating that information to oncologists.2,3 Oncology nurses can advocate for appropriate treatment by using treatment guideline recommendations to suggest changes to non-guideline-adherent orders.13 The patient’s risk factors for CINV should be assessed before chemotherapy begins.9 Online resources, such as Oncology Nursing Society’s Clinical Practice resource, can provide helpful information. In general, patients who are more likely to experience CINV can be identified by several factors. Female patients are at elevated risk, as are those who are young, have a history of low alcohol intake, experienced emesis during pregnancy, have an impaired quality of life, or have previously experienced chemotherapy.6,14,15 Currently, specific prophylaxis is not generally based on patient risk factors but rather on the emetogenicity of the chemotherapy administered, though considering a combination of the two has been suggested.2,6,14 In addition to patient evaluation for risk factors, concomitant medications are an important aspect of the nursing assessment. These should be considered both as a risk factor for nausea and vomiting and for potential interactions with CINV prophylactic agents.3 Challenges in the effective management of CINV include underestimation of its prevalence by health care providers.16 Prevalence of CINV may be under-reported for many reasons.17 Chemotherapy agents are divided into low, moderate, and high risk of emetogenicity, with ranges of risks reported. Those ranges are likely to be both overestimations and underestimations of the true risk for CINV, which vary from patient to patient. In addition, the ranges are based on acute CINV and do not take into account either anticipatory or delayed CINV. Despite their potential benefits, oral chemotherapies also pose particular challenges in terms of ensuring adherence and managing side effects.18 The use of outpatient facilities to administer chemotherapy creates a barrier to direct observation of CINV symptoms, in particular the delayed

22 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

type, by health care personnel in general and oncology nurses specifically.17,18 Other potential reasons for the underestimated prevalence of CINV are patients’ desire to avoid complaining to their physicians and physician assumption that patients will recognize CINV as a problem that should be reported. Overall, delayed CINV may be more common than acute CINV as it is less likely to be reported, and therefore also less likely to be treated effectively.17,19 Ample evidence exists to show that adherence to antiemetic guideline recommendations can improve clinical outcomes.6,20 In general, adherence rates for prophylactic treatment of delayed CINV are substantially lower than for acute CINV. One study revealed adherence to antiemetic guidelines for acute CINV was 75.5%, whereas adherence to antiemetic guidelines for delayed CINV ranged from 36.4% for HECs to 90.0% for those with lower emetogenic potential.21 In addition, although adherence to antiemetic guidelines did not reduce acute CINV rates, adherence was associated with a significant reduction in delayed CINV.21 A study by Gilmore and colleagues found that 57.3% of patients received guideline-consistent CINV prophylaxis, and the no-CINV rate was higher in these patients compared with those whose prophylaxis treatment was inconsistent with guidelines (P<.001).22 Another study found that, in the absence of intervention, guideline-adherent antiemesis for MEC was 100% in the acute period but only 6.6% in the delayed period.23 For those patients who received an intervention designed to increase guideline-adherent antiemesis (89%), their care was indeed more adherent with guidelines, and 20% more patients achieved complete protection from CINV compared with the nonintervention group.23 Overall, a relationship between adherence to antiemetic guidelines and reductions in CINV is supported.22,23

When multiple chemotherapies are planned, antiemetic therapy should be based on the chemotherapy with the highest emetic risk. Evaluating the success of antiemesis procedures is crucial to effective patient treatment. A follow-up phone call or administering a patient reporting tool to better examine the true incidence of CINV in your practice is recommended.17 Patient education To help patients play an active role in reducing CINV, nurses should provide information on its symptoms and management, preferably in a form that is

easy-to-read and understand, taking into account variations in patients’ educational levels.9 Patient education materials should include information on nutrition and eating habits that help reduce nausea. Patients should be encouraged to keep a diary or journal of symptoms and to adhere to CINV prevention regimens.3,9 Simple nutrition counseling, such as eat smaller and more frequent meals, avoid spicy or fatty foods, and use measures that worked for them in the past to minimize nausea, should be offered.2 Finally, patients should have access to telephone support to help manage their symptoms.9 Nurse education Several methods of improving adherence to antiemetic guidelines among health care providers have been evaluated.2,9 Those methods proven to be effective are generally multifaceted and include education, patient feedback, standardized prescription order sheets based on guidelines, and auditing/feedback from other staff.6,17,20,24 Feedback regarding both deviation from guideline recommendations and patient experience with CINV was particularly effective, according to one study, especially when paired with a new policy of specialized nurse practitioners administering all prescriptions for CINV prophylaxis.24 GUIDELINE RECOMMENDATIONS The goal of antiemetic therapy is always prevention, both for maintaining patient quality of life and also for preventing anticipatory nausea and vomiting.5 Therefore, treatment for both acute and delayed emesis prevention should begin before chemotherapy.5,25 When multiple chemotherapies are planned, choice of antiemetic therapy should be based on the chemotherapy with the highest emetic risk, taking other patient risk factors into account as well.5 Most guidelines provide recommendations according to timing of CINV (acute vs delayed) or chemotherapeutic emetogenicity levels ( Table 1). Further considerations when choosing a specific agent are safety and tolerability. Dexamethasone is associated with side effects such as insomnia.5 Aprepitant (Emend, generics) affects the cytochrome P450 enzyme 3A4 (CYP3A4) and induces CYP2C9; therefore, it can alter the metabolism of a significant number of medications including pimozide (Orap), cisapride (Propulsid), warfarin, and several chemotherapeutic agents.5 Some 5-HT3 receptor antagonists are associated with an increased risk for cardiac arrhythmias or prolongation of the QT interval.5,25 Patients who may be particularly at risk for developing torsades de pointes, such as those with congenital long QT syndrome or other underlying cardiac diseases, or who are taking other medications associated with QT prolongation, should be monitored via electrocardiography (ECG) during treatment.5 Palonosetron (Aloxi, generic) has not been

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 23

CONTINUING EDUCATION | CINV guidelines associated with prolongation of the QT interval or other changes in ECG parameters.26,27 Acute CINV Either a neurokinin-1 (NK1) antagonistcontaining regimen or an olanzapine (Zyprexa, generics)containing regimen is recommended for preventing acute CINV in patients undergoing treatment with a HEC. The NK1 antagonist-containing regimen should be a combination of a 5-HT3 receptor antagonist (preferably palonosetron), dexamethasone, and aprepitant/fosaprepitant (Emend).5 Alternatively, the 2014 National Comprehensive Cancer Network (NCCN) Guidelines also include an olanzapine-containing regimen (olanzapine, palonosetron, and dexamethasone) based on study findings from Navari and colleagues.5,28 Lorazepam (Ativan, generics) and an H2 blocker or proton pump inhibitor (PPI) may also be included with either the NK1 regimen or the olanzapine regimen.5 For prophylaxis of acute nausea and vomiting with a MEC, a 5-HT3 receptor antagonist (preferably palonosetron) plus dexamethasone is recommended.2,5,6,25 Similar to HEC, the 2014 NCCN Guidelines include an alternative olanzapine-containing regimen (olanzapine, palonosetron, and dexamethasone).5 Also similar to HEC, lorazepam and an H2 blocker or PPI may be included with either the NK1 regimen or the olanzapine regimen.5 Adjunctive use of aprepitant or fosaprepitant in this instance has been either recommended or considered optional.2,4,6,25,29 Prophylaxis for CINV with a LEC may consist of a corticosteroid, 5-HT3 receptor antagonist, or dopamine receptor antagonist5,6,25; however, some recommendations include only dexamethasone.29 Finally, minimally emetogenic chemotherapy does not require any treatment for the possibility of acute CINV.5,6,25,29 Delayed CINV Recognition of delayed CINV may be low among health care providers due to the nature of this effect.3,30 Quality of life, however, is diminished even when only delayed CINV episodes occur.31 For HEC agents, those guidelines that distinguish acute from delayed CINV recommend a combination of dexamethasone and aprepitant for delayed CINV.25 If fosaprepitant is given on day 1, however, no additional dose of fosaprepitant is necessary.6,25 Dexamethasone or aprepitant are suggested for prophylaxis of delayed nausea and vomiting with a MEC agent.6,25 If aprepitant was used for prevention of acute CINV, it should continue to be used for delayed CINV, whereas if palonosetron was used, it is not needed again.6 LEC and minimally emetogenic chemotherapy do not require prophylactic treatment for delayed CINV.5,6,25,29 Breakthrough and anticipatory CINV Breakthrough or refractory CINV indicates a need to evaluate emetic risk,

disease status, concurrent illnesses, and medications; and the antiemetic regimen should be re-examined to make sure that the most appropriate treatment is being administered for the emetic risk.29 In general, an agent from a drug TABLE 1. Recommended antiemesis treatments for intravenous chemotherapy2,5,6,27,28 HIGH EMETIC RISK NK1 antagonist-containing regimen Serotonin (5-HT3) antagonist: • Dolasetron, or • Granisetron, or • Ondansetron, or • Palonosetron (preferred) and Steroida/dexamethasone and NK-1 antagonist ± Lorazepam ± H2 blocker or PPI

Olanzapine-containing regimen Olanzapine Palonosetron Dexamethasone ± Lorazepam ± H2 blocker or PPI

MODERATE EMETIC RISK Serotonin (5-HT3) antagonist: • Dolasetron, or • Granisetron, or • Ondansetron, or • Palonosetron (preferred) and Steroid/dexamethasone with/without NK-1 antagonist ± Lorazepam ± H2 blocker or PPI LOW EMETIC RISK Dexamethasone ± Lorazepam prn ± H2 blocker or PPI or Substituted benzamide/metoclopramide ± Lorazepam prn ± H2 blocker or PPI or Phenothiazine/prochlorperazine ± Lorazepam prn ± H2 blocker or PPI or Serotonin (5-HT3) antagonista (PO) • Dolasetron, or • Granisetron, or • Ondansetron ± Lorazepam prn ± H2 blocker or PPI Note: Routine prophylaxis is not necessary for minimal emetic risk chemotherapies. a Some recommendations advise against the use of 5-HT3 antagonists for low emetogenic therapy. Key: 5-HT3, 5-hydroxytryptamine; NK-1, neurokinin-1; PPI, proton pump inhibitor; prn, as needed.

24 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

class not previously used should be added to the treatment regimen.2,5 Olanzapine, lorazepam, dronabinol, nabilone (Cesamet), and oral 5-HT3 receptor antagonists are among the potential therapies.2,5 If the additional agent is effective, it should be continued to prevent additional symptoms.5 If CINV continues despite the new agent, dose adjustments or another agent should be considered.5 Regardless of whether the new agent is effective, using a higher level antiemetic therapy as primary treatment should be considered for the next chemotherapy cycle.5 The best strategy for anticipatory CINV is optimal antiemetic therapy.5,25,29 When anticipatory CINV occurs, however, it may be addressed through behavioral therapy such as relaxation, hypnosis, or systematic desensitization; acupuncture/acupressure; or alprazolam or lorazepam.2,5,25,29 Multiday chemotherapy regimens Prevention or treatment of CINV with multiday chemotherapeutic regimens is complicated by the need to address the potential for both acute and delayed CINV at each day of treatment. The possible overlap of acute and delayed CINV, the varying emetogenic potential of the individual agents, and the sequence of administration should all be taken into account.5,29 Treatment may include corticosteroids, 5-HT3 receptor antagonists, and/or NK1 antagonists.5 Some concerns are centered around repeated dosing of the antiemetics used. If dexamethasone is used, for example, side effects associated with its prolonged administration need to be taken into account. Although concerns have not been noted for repeated dosing of palonosetron, a single IV palonosetron dose of 0.25 mg may be sufficient if administered prior to the start of a short (3-day) chemotherapy regimen.5 Oral chemotherapy Oral chemotherapies are also divided into high-, moderate-, and low-to-minimal emetogenic risk categories. For high-to-moderate risk therapies, an oral 5-HT3 antagonist (dolasetron [Anzemet], granisetron [Kytril, Sancuso, generics], or ondansetron [Zofran, Zuplenz, generics]) is recommended.5 Similar to recommendations for IV chemotherapies, lorazepam and/or an H2 blocker or proton pump inhibitor may also be added. For low-to-minimal risk chemotherapies, treatment is administered as needed.5 In the event that treatment is necessary, metoclopramide, prochlorperazine, haloperidol, or an oral 5-HT3 receptor antagonist is recommended.5 Again, lorazepam and/or an H2 blocker or proton pump inhibitor may also be added.

improving detection and assessment of CINV, encouraging adherence to guidelines, educating patients regarding treatment options, obtaining feedback from patients regarding antiemetic treatment efficacy, and suggesting changes when appropriate. To do this, oncology nurses should remain up to date on changes in guidelines. In this way, reductions in CINV rates can be made through effective prophylactic treatment, improving health care quality and efficiency. ■ Acknowledgment The authors wish to thank Jennifer Steeber, PhD, of MedVal Scientific Information Services, LLC, for providing medical writing and editorial assistance. This study and manuscript were supported by funds provided by Eisai Inc. Una Hopkins is administrative director, White Plains Cancer Center in White Plains, New York; and a member of the speakers’ bureau for Eisai Inc (2009-2014) and Bristol-Myers Squibb (2011-2013). Diana Donovan is a nurse practitioner at Dubin Breast Center, Mount Sinai Hospital in New York, New York. REFERENCES 1. Rugo HS. Diagnosing and treating chemotherapy-induced nausea and vomiting: understanding the need and clinical data for best patient cancer care. Oncol Rev. 2014;(suppl):3-8. 2. Tipton JM, McDaniel RW, Barbour L, et al. Putting evidence into practice: evidence-based interventions to prevent, manage, and treat chemotherapyinduced nausea and vomiting. Clin J Oncol Nurs. 2007;11(1):69-78. 3. Hawkins R, Grunberg S. Chemotherapy-induced nausea and vomiting: challenges and opportunities for improved patient outcomes. Clin J Oncol Nurs. 2009;13(1):54-64. 4. Brooks M. Nurses champion guideline-based antiemetic therapy. Medscape Multispecialty Web site. http://www.medscape.com/viewarticle/825047. Accessed September 26, 2014. 5. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Antiemesis. Version 2.2014. Fort Washington, PA: National Comprehensive Cancer Network; 2014. 6. Jordan K, Gralla R, Jahn F, Molassiotis A. International antiemetic guidelines on chemotherapy induced nausea and vomiting (CINV): content and implementation in daily routine practice. Eur J Pharmacol. 2014;722:197-202. 7. Janelsins MC, Tejani MA, Kamen C, et al. Current pharmacotherapy for chemotherapy-induced nausea and vomiting in cancer patients. Expert Opin Pharmacother. 2013;14(6):757-766. 8. Fernández-Ortega P, Caloto MT, Chirveches E, et al. Chemotherapy-induced nausea and vomiting in clinical practice: impact on patients’ quality of life.

SUMMARY

Support Care Cancer. 2012;20(12):3141-3148.

The management of CINV, as assessed by adherence to antiemetic guidelines, is often suboptimal. Nurses can play a significant role in reducing the incidence of CINV and improving patient care by evaluating patient risk factors for CINV,

9. Vidall C, Dielenseger P, Farrell C, et al. Evidence-based management of chemotherapy-induced nausea and vomiting: a position statement from a European cancer nursing forum. Ecancermedicalscience. 2011;5:211. References continue on page 26

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CONTINUING EDUCATION | CINV guidelines 10. Hassan BA, Yusoff ZB. Negative impact of chemotherapy on breast cancer

23. Fujii H, Iihara H, Ishihara M, et al. Improvement of adherence to guidelines for

patients QOL – utility of antiemetic treatment guidelines and the role of race.

antiemetic medication enhances emetic control in patients with colorectal

Asian Pac J Cancer Prev. 2010;11(6):1523-1527.

cancer receiving chemotherapy of moderate emetic risk. Anticancer Res.

11. Weaver C, Schiech L, Held-Warmkessel J, et al. Risk for unplanned hospital readmission of patients with cancer: results of a retrospective medical record review. Oncol Nurs Forum. 2006;33(3):E44-E52.

2013;33(12):5549-5556. 24. Mertens WC, Higby DJ, Brown D, et al. Improving the care of patients with regard to chemotherapy-induced nausea and emesis: the effect of feedback

12. Lindley CM, Hirsch JD, O’Neill CV, et al. Quality of life consequences of chemotherapy-induced emesis. Qual Life Res. 1992;1(5):331-340.

to clinicians on adherence to antiemetic prescribing guidelines. J Clin Oncol. 2003;21(7):1373-1378.

13. Ahern K, Cappo K, Corish N, et al. An analysis of adherence to NCCN clinical practice guidelines in oncology (NCCN guidelines) for antiemesis V.1.2013. Presented at: 39th Annual Congress of the Oncology Nursing Society; May 1-4, 2014; Anaheim, CA.

25. Gralla RJ, Roila F, Tonato M, Herrstedt J. MASCC/ESMO antiemetic guideline 2013. http://mascc.memberclicks.net/assets/documents/mascc_guidelines_ english_2013.pdf. Accessed September 26, 2014. 26. Schwartzberg L, Barbour SY, Morrow GR, et al. Pooled analysis of phase III clini-

14. Warr D. Prognostic factors for chemotherapy induced nausea and vomiting. Eur J Pharmacol. 2014;722:192-196.

cal studies of palonosetron versus ondansetron, dolasetron, and granisetron in the prevention of chemotherapy-induced nausea and vomiting (CINV).

15. Grunberg SM, Hesketh PJ. Control of chemotherapy-induced emesis. N Engl J Med. 1993;329(24):1790-1796.

Support Care Cancer. 2014;22(2):469-477. 27. Musso M, Scalone R, Crescimanno A, et al. Palonosetron and dexamethasone

16. Hopkins U. Current clinical practice for chemotherapy-induced nausea and vomiting: understanding the up-to-date evidence-based guidelines for

for prevention of nausea and vomiting in patients receiving high-dose chemotherapy with auto-SCT. Bone Marrow Transplant. 2010;45(1):123-127.

prevention and treatment. Oncol Rev. 2014;(suppl):9-14.

28. Navari RM, Gray SE, Kerr AC. Olanzapine versus aprepitant for the prevention

17. Grunberg SM. Chemotherapy-induced nausea and vomiting incidence and prevalence. Am Soc Clin Oncol Educ Book. 2012:541-543.

of chemotherapy-induced nausea and vomiting: a randomized phase III trial. J Support Oncol. 2011;9(5):188-195.

18. Kav S, Johnson J, Rittenberg C, et al. Role of the nurse in patient education and follow-up of people receiving oral chemotherapy treatment: an international survey. Support Care Cancer. 2008;16(9):1075-1083.

29. Basch E, Prestrud AA, Hesketh PJ, et al; American Society of Clinical Oncology. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2011;29(31):4189-4198.

19. Cohen L, de Moor CA, Eisenberg P, et al. Chemotherapy-induced nausea

30. Grunberg SM. Obstacles to the implementation of antiemetic guidelines.

and vomiting: incidence and impact on patient quality of life at community oncology settings. Support Care Cancer. 2007;15(5):497-503.

J Natl Compr Canc Netw. 2009;7(5):601-605. 31. Bloechl-Daum B, Deuson RR, Mavros P, et al. Delayed nausea and vomit-

20. Kadakia KC, Leal AD, Seisler DK, et al. Antiemetic prescribing practices

ing continue to reduce patients’ quality of life after highly and moderately

using a computerized physician order entry system. Support Care Cancer.

emetogenic chemotherapy despite antiemetic treatment. J Clin Oncol.

2014;22(1):217-223.

2006;24(27):4472-4478.

21. Rubenstein EB, De Moor C, Cohen L, et al. Outcomes of patients (pts) receiving emetogenic chemotherapy (CT): How do oncologist’s (MD’s) practice patterns of antiemetic prescribing change after pts experience acute or delayed CINV? J Clin Oncol. 2004;22(14S):Abstract 8256. 22. Gilmore JW, Peacock NW, Gu A, et al. Antiemetic guideline consistency and incidence of chemotherapy-induced nausea and vomiting in US community

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ONCOLOGY NURSE ADVISOR FORUM

ASK A PHARMACIST

QUESTIONS & ANSWERS

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

Jia R. Conway, DNP, FNP-BC, NP-C, 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.

Ideally, a patient navigation tool is easy for the patient to use, and the patient can easily understand the information provided. Many patients are savvy Internet users and have at least one device with which to access the Internet; therefore, web-based resources are helpful. Other advantages include the resource is more likely to be upto-date each time the patient refers to it; the resource is usually available 24 hours a day, 7 days a week; and a greater selection of resources may be available. In addition, some web-based tools are designed specifically for navigators for monitoring patient status and where patients are along the continuum of care. This method usually also allows for creating end-of-treatment documentation that can be shared with the patient and their primary care physicians. This tool then allows all who might be caring for the patient (now survivor) to correctly order needed follow up studies, etc, to do lifetime monitoring. Printed materials, however, have a few advantages as well. They can be handed to the patient and easily reviewed in person. Patients can show their nurses which information is confusing to them and ask questions, and nurses can be more confident the patient is referring to reliable information. Disadvantages include the increased administrative work to maintain the supply of materials, as well as keeping the supply up-to-date. The ideal time to introduce a patient navigation tool is at the first patient-education session with the patient’s nurse. Then, at each subsequent visit, the navigation tool can be reviewed, updated, and adjusted to the patient’s information needs. As with many aspects of cancer care, an approach tailored to the patient’s needs is the most effective one. For many patients, a combination of both Web-based resources and printed materials would provide the information they need in a format that enables them to navigate their cancer journey. —The Editors

SOME PORT MAINTENANCE IS OUTSIDE THE SCOPE OF NURSING PRACTICE Is it within a nurse’s scope of practice to flip a port over with a physician’s order? I am getting mixed responses from colleagues, and cannot find any literature that either supports or refutes nurses performing this task. —Jennifer Edwards, RN, BSN, OCN

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

This is a controversial question, as nursing practice can differ from state to state. That being said however, Oncology Nursing Society’s standards for caring for vascular

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

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CREATING EFFECTIVE NAVIGATION TOOLS FOR PATIENTS Would a patient navigation tool be Web-based resources, printed materials, or both? Which member of the treatment team is the ideal person to introduce the resource to the patient and when? — Robert Mark Baldridge

Conceptual illustration of a stimulated site of pain (ball of barbed wire)

Managing peripheral neuropathy related to vincristine Has any medicine or supplement been shown to help lessen severity of peripheral neuropathy related to vincristine? Glutamine or gabapentin has not been successful in our experience. —Carrie L Lewis, RN, MSN, CPNP, CPON

Vincristine (Oncovin) is used in the treatment of a variety of cancers, including some leukemias and lymphomas. Rates of peripheral neuropathy with vincristine vary between regimens and patient populations, and have been reported in 35% to 45% of patients in some studies. Risk factors for development of peripheral

neuropathy include higher doses of vincristine, larger cumulative doses of vincristine, the presence of baseline neuropathy, and some drug-drug interactions. Patients experiencing peripheral neuropathy due to vincristine may experience pain, tingling, numbness, and reduced sensation in the hands and feet. Management of peripheral neuropathy may depend on the severity of symptoms and the patient’s treatment course. Patients with clinically significant neuropathy during vincristine therapy should be monitored closely and considered for a dose-reduction or vincristine discontinuation. Improvement or resolution of neuropathy may take up to 2 years, and some patients may experience a worsening of their neuropathy symptoms after vincristine is discontinued. Unfortunately, some patients may have ongoing neuropathy even after this time. Treatment options for vincristine and other chemotherapy-induced peripheral neuropathy include tricyclic antidepressants (eg, amitriptyline [Elavil]), anticonvulsants (eg, carbamazepine [Tegretol]), gabapentin (Neurontin), pregabalin (Lyrica), and serotoninnorepinephrine reuptake inhibitors (eg, duloxetine [Cymbalta]). Some supplements, such as glutamine and pyridoxine, have also been studied in the prevention of peripheral neuropathy. Although multiple agents have been studied to treat chemotherapy-induced peripheral neuropathy, no agents have consistently shown a benefit in randomized phase 3 clinical trials. Opioids

or other analgesics may be required to control pain symptoms in patients whose pain is not managed. Early detection of vincristine-induced peripheral neuropathy with appropriate adjustment of a patient’s vincristine therapy is critical to reduce the risk of long-term neuropathy symptoms after treatment. Patients with persistent symptoms should be referred to a neurologist for a thorough work-up and consideration of alternate therapies. Working with an occupational therapist may also be helpful to restore lost function due to neuropathy. TIP FOR PATIENTS National Drug Take-Back Day: April 26, 2014

Spring 2014 DEA Drug Take Back Day events will be held on Saturday, April 26, from 10 AM to 2 PM. These events are a great way for patients to dispose of expired or unwanted medications, including controlled substances such as pain medications. Since beginning in 2010, these events have disposed of more than 1,733 tons of prescription medications. For more information, including collection sites in your area, please visit www.deadiversion.usdoj.gov/ drug_disposal/takeback/ after April 1st. For information on how to advise patients regarding other ways to dispose of nonchemotherapy medications, please visit www.oncologynurseadvisor.com/ educating-patients-about-the-properdisposal-of-old-drugs/article/168850/. ■

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

Let us answer your questions! E-mail us at editor.ona@haymarketmedia.com with your general questions for our expert Advisor Forum and your drug-related questions for Ask a Pharmacist!

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FEATURE | Role for chaplaincy

Navigating nonclinical patient care: A review of chaplaincy Get the chaplain, STAT!? A novel study examines perceptions of the role of the hospital chaplain. What do they do? When should they be called in? DAVID McDANIEL

bservational research on the role of a chaplain and how he or she interacts with patients and families is limited. Most studies on the role of chaplains are heavily dependent on self-reports generated by the chaplain and lack direct observation by an independent reviewer. For example, Gibbons and colleagues reported on a project in which chaplains selfreported in a diary the work they performed after providing pastoral care.1 Flannelly investigated the process of chaplain referrals in 2-week increments over 3 years, but specifically focused on the interventions performed by the chaplains.2 Cadge interviewed both pediatricians and chaplains, wanting to learn how each group saw the role of the chaplain.3 The pediatricians described the chaplain as a member of the interdisciplinary team who provided rituals and support for patients and families, especially in regard to the death experience. The chaplains, however, perceived their role in a broader context not limited just to times of death, but also as assisting in wholeness to the patient and by simply being present with the patient and family. Again, these interventions were self-reported by the chaplains.3 Other studies focused on the role of the chaplain in crisis situations. Of note, Puchalski wrote, “The chaplain seeks only to engage the sufferer and to reframe his/her suffering in the context of life’s incongruities.”4 This implies that as a member of the interdisciplinary team, the chaplain has a limited agenda with the patient. In a similar way, O’Connor describes how chaplains

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FEATURE | Role for chaplaincy

restrict their own theology to allow patients to explore their spirituality as influenced by the present crisis narrative in the hospital.5 In particular, Freyer and colleagues studied the work of the interdisciplinary team when working with adolescents who are dying.6 Their study suggests the role of the chaplain is to “support the adolescent’s search for spiritual meaning.”6 The oncology ward is a ripe location for collaboration between the medical staff who provide care for patients with cancer and the chaplain. Blanchard noted that spiritual distress in cancer patients can compromise health outcomes, so they created a two-question screening tool oncology nurses can use when admitting a patient with cancer.7 Patients’ answers determine the need for a referral to the chaplain. Johnson and colleagues discussed the feasibility and benefits of using centering prayer for women with recurrent ovarian cancer.8 King investigated oncology physicians’ attitudes toward their patients’ spiritual health.9 These researchers discovered that clinicians who had an understanding of chaplaincy tended to offer referrals to chaplains more often. BUILDING AN OBJECTIVE PERSPECTIVE In 2012, a cohort of pediatric chaplains, led by John Lantos, MD; Dane Sommer, DMin, BCC; and Jennifer Hunter, RN, PhD, began to fill a void in chaplain research by designing a study to investigate chaplains working in pediatric crisis situations. The study was funded by the John Templeton Foundation, with the grant program managed by HealthCare Chaplaincy Network, and was conducted in a Midwestern, free-standing pediatric hospital. The goal of the study was to answer the following three questions: • How do chaplains respond to parents who are faced with life-threatening crisis in their child? • How do chaplains understand and incorporate their theoretical and theological conceptual frameworks into the work that they do? • What commonalities and differences exist through which chaplains provide assistance to these parents? METHODOLOGY The study was qualitative in nature; methods included observation, reflection, and interview. A research observer followed each chaplain for 72 hours during which the chaplain worked with a critically ill patient. A total of seven cases were completed. Inclusion criteria were English-speaking patients who were admitted to the hospital, specifically the Emergency Department, Pediatric Intensive Care Unit, and the Neonatal Intensive Care Unit. The chaplains themselves wrote an

exhaustive case study on what they perceived they did while working with the patient and families, and the observer wrote a case study of what he perceived the chaplains were doing. Specific attention was given to the context and mood of the encounters, what family members said, what the chaplain

Physician and nurse interviews revealed they were uncertain about what the chaplain did while with patients and families. said, how it was said, nonverbal communications, and also some of what was not said. After the 72-hour observation period, the observer then interviewed the physicians and nurses who worked with the patient to gain their perspective of what the chaplain did. All of the reports were presented to an interdisciplinary panel that reviewed each case and discussed the role of the chaplain. The panel consisted of a narrative scholar, a member of the hospital Family Advisory Council, a hospital chaplain from another institution, a palliative care physician, a communications specialist, a pediatric intensive care nurse, and a child psychologist. And last, the families of the patients were also interviewed approximately 6 months after the 72-hour observation period. As a final step, the reports and interviews were subjected to qualitative analysis. Themes within each case and across all of the cases were brought to light. STUDY FINDINGS Analysis of the reports and interviews revealed that answers to the question “What do chaplains do?” could be categorized into four main themes: (1) Health care providers are unsure of what chaplains actually do while working with the patient and family. (2) Chaplains regularly give patients and families tangible objects that symbolize hope. (3) Chaplains use physical touch to build trust. (4) When families request prayer, chaplains use this ritual as an invitation into a holy space. Health care provider uncertainty The physician and nurse interviews revealed they were uncertain about what the chaplain actually did while with the patients and families. However, nurses were able to provide more specific details

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FEATURE | Role for chaplaincy of the interactions with the chaplain. Physicians rarely interacted with the chaplain. The following samples reflect the physicians’ responses when asked about their perception of the chaplain’s role in the particular case. “I wasn’t in [the room] for a lot of interaction with the chaplain.” “… I would have to say I actually did not have much interaction with the chaplain. [In fact] I did not have any direct interaction.” “I did not have an opportunity to work with the chaplain in this case.”

When nurses were asked the same question, they stated: “Just kind of being a support for the parents.” “The chaplain came to the bedside and was very supportive and helpful, answered questions, and let the family know that they were available if the family wanted to talk or needed other resources, whether that be something more concerning with their specific religion, etc.” “I think that I’ve seen the chaplain offer support to the parents. The parents have had a lot of shock and upset … and I feel that chaplaincy has been a great part of them getting through the day-to-day challenges.”

Curiously, even though the health care providers were limited in describing the role of the chaplain in the particular case, when asked if they perceived the chaplains as having been helpful in the situation, they all replied in the affirmative. “The first 24 hours of admission for these babies are very hard for the parents. There is a lot of information coming on. There is uncertainty … so, I think this is really where the chaplain can play a very vital role, by coming in on admission and talking to the parents, visiting with them, and trying to help them put things together … Giving them spiritual support would be very helpful. “I think it’s important for chaplaincy to gauge kind of where the parents are at and what kind of support they need or could potentially need in the future.” “For most families, at least in this part of the country, having some sort of spiritual help, guidance, support helps them get through the next however many hours or days that their child survives or doesn’t survive.”

Tangible objects Chaplains often gave families various tangible objects that symbolized hope. In five cases, the chaplain gave the parents a prayer shawl; in the other two cases, the chaplain gave the parent a book with a recorder attached to it. When handing the prayer shawls to a family member, the clergy told the parents that the person who made the blanket had prayed for the child as the blanket was being made. As the observation period progressed, research observers noted that each of the families had either covered the sleeping child with the prayer shawl or the shawl had been placed with the family’s personal belongings in the room. The book with the recorder allowed the parent to record his or her own voice reading the story, then if the parent had to leave

for the night or was away from the child, a hospital employee could play the book recording and the patient could hear their parent’s voice. On receiving the gift from the chaplain, some parents became emotional and appeared to gain a sense of peace knowing that their child would still be connected to them, even when they were not physically present. Physical touch Physical interaction was noted to be of high value with the chaplain and the patients’ families. In each of the seven cases, some type of physical touch was noted. The most common form was the chaplain placing a hand on the shoulder of a family member. In one case, a child was admitted to the hospital for nonaccidental trauma. While in the trauma bay of the Emergency Department, the patient’s mother stood over her child crying and kissing his forehead. The maternal grandmother stood on the opposite side of the bed, and the chaplain was behind the mother with a hand on her shoulder. In another case, as a baby was being placed on ECMO, the chaplain stood by the watching father with a hand on his shoulder. In one chaplain’s reflective writing, the physical touch was described as an affirmation to the parent that he or she was not alone. In addition, most of the chaplains seemed to intentionally maintain an eye-level position with the parent. If the parent stood, so did the chaplain. If the parent sat, the chaplains would typically either sit, too, or bend at the waist. Prayer The chaplains used ritual prayer; however, this was initiated only when family members indicated it was a valued resource for them. One chaplain would ask if the parent would like to pray or if they wanted the chaplain to lead the prayer. This allowed the family member to have some power and control in

A chaplain’s services can be of value to the patient or family during the journey involving cancer. a situation in which they typically feel they do not have much control at all. The chaplain assisted in creating a holy space for the patient and family, and then invited the family member to direct the space. Another chaplain, after inquiring what the family would like prayer for, incorporated the parent’s words and phrases into the prayer. Of note, in one parent interview, a mother stated, “It was comforting to know that [the chaplain] was praying for me, but we never prayed together.” Another family member said, “[The chaplain’s] prayers were the only thing that enabled me to get through [the crisis].”

34 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

DISCUSSION Chaplains find themselves in an in-between area of the hospital. On one hand, the chaplain is part of the hospital team providing patient care. Although not providing physical medical care, the chaplain does assist in the totality of care for the patient and the family. Chaplains assist explicitly with religious practices and rituals for patients and families, while also acting implicitly as a physical representation of divinity and spirituality. On the other hand, the chaplain advocates for patients and families while they are in the hospital. The chaplain journeys with the patients and families, listening to their story, and helping them articulate meaning during their time of uncertainty. The chaplain is then able to take the family’s understanding back to the medical team, thus assisting with communication and understanding between the two groups. Although this study used critically ill pediatric patients as the clinical setting, a correlation can be used in the oncology ward. Oncology patients find themselves in the midst of uncertainty, whether it is a recent diagnosis, a time of relapse, or at the end stages of life. A chaplain’s services can be of value to the patient or family during the journey involving cancer. One chaplain from this study stated, “One of my roles is to journey with people—walk with them and provide a caring presence. Sometimes I lead them as I try to anticipate needs and provide information early in a family’s stay.” Because the chaplain is part of the hospital staff, he or she has the ability to anticipate what the future might hold for the patient and can help guide them during this time of their life. In addition, regardless of whether tangible objects, physical touch, prayer, or other like actions are used, the chaplain, at the end of the day, is a physical representation of the divine. The chaplain is there to offer hope that something greater than the patient is journeying with them, that the patient is not alone, that no matter what happens the patient is being paid attention to, even if the road must travel through the shadow of death. One chaplain described part of her job as the notion of holy listening to the patient and family. “While, yes, it is listening to the patient’s story, including their fears and excitement, it is also listening with intentionality, with an ear toward being that vessel, the conduit of the divine.” And this type of listening is ripe in the oncology ward as patients are imminently dealing with issues of mortality, frailty, and the uncertainty of why this is happening.

family. These interventions allow patients and families to slowly take in and come to grips with life-altering situations that affect both the patient and the family. Chaplains, while representing the divine, humanize the experience and act as a connection to the current patient situation and the greater hopefulness of the patient and family, no matter what happens. Chaplains use knowledge of the system within the hospital, are trained in listening skills bent toward deeper meanings, understand liturgical practices, and most importantly, have time to be with the patient and family. By using all of this, the chaplain assists the patient in making sense of the current circumstance and aides in finding meaning through his or her surroundings. And, so the chaplain journeys … with the hospital staff, with the patient, with the family members. Whether the path travels through the highest of peaks or through the shadow of death, chaplains are there, being, representing, listening, reflecting, offering, and initiating a sense of hope, no matter who the person is or what their story is. And whether the path travels to life, to death, or to a new normal, the chaplain is there with hope. The chaplain is a conduit of the divine. ■ David McDaniel is a staff chaplain at Children’s Mercy, Kansas City, Missouri. REFERENCES 1. Gibbons G, Retsas A, Pinikahana J. Describing what chaplains do in hospitals. J Pastor Care. 1999;53(2):201-207. 2. Flanelly KJ, Weaver AJ, Handzo GF. A three-year study of chaplains’ professional activities at Memorial Sloan Kettering Cancer Center in New York City. Psychooncology. 2003;12(8):760-768. 3. Cadge W, Callie K, Dillinger J. What do chaplains contribute to large academic hospitals? The perspectives of pediatric physicians and chaplains. J Relig Health. 2011;50(2):300-312. 4. Puchalski CM, Lunsford B, Harris MH, Miller T. Interdisciplinary spiritual care for seriously ill and dying patients: a collaborative model. Cancer J. 2006;12(5):398-405. 5. O’Connor TS. The search for truth: the case for evidence based chaplaincy. J Health Care Chaplain. 2002;13(1):185-194. 6. Freyer DR, Kuperberg A, Sterken DJ, et al. Multidisciplinary care of the dying adolescent. Child Adolesc Psychiatr Clin N Am. 2006;15(3):693-715. 7. Blanchard JH, Dunlap DA, Fichett G. Screening for spiritual distress in the oncology inpatient: a quality improvement pilot project between nurses and chaplains. J Nurs Manag. 2012;20(8):1076-1084. 8. Johnson ME, Dose AM, Pipe TB, et al. Centering prayer for women

CONCLUSION Importantly, specifically categorizing the role of the chaplain is difficult. If the role of the hospital chaplain was compressed into one thought, one might say chaplains use specific interventions to build a trusting relationship with the patient and

receiving chemotherapy for recurrent ovarian cancer: a pilot study. Oncol Nurs Forum. 2009;36(4):421-428. 9. King SD, Dimmers MA, Langer S, Murphy PE. Doctors’ attentiveness to the spirituality/religion of their patients in pediatric and oncology settings in the Northwest USA. J Health Care Chaplain. 2013;19(4):140-164.

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 35

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STAT CONSULT Trastuzumab (Herceptin) Drug type © GENENTECH, INC.

• Recombinant DNA-derived humanized anti-HER2 (human epidermal growth factor receptor 2 protein) monoclonal antibody • Antineoplastic agent

Indications

Initial dose of 8 mg/kg over 90 minute IV infusion followed by 6 mg/kg over 30-90 minutes IV infusion every 3 weeks • Administration ——IV infusion with initial dose administered over 90 minutes ■■ If first dose is well-tolerated, subsequent doses may be infused over 30 minutes ■■ Do not administer by rapid IV injection, IV push, or bolus ——Prior to administration: ■■ Do not dilute solutions for infusion in, or administer through, an IV line containing 5% dextrose injection ■■ Do not mix or dilute with other drugs ■■ Inspect trastuzumab solutions for particulate matter and discoloration ——Premedication ■■ If patients have had prior sensitivity, acetaminophen, diphenhydramine, and/or a corticosteroid may be given ——Common IV compatibilities (via Y-site) ■■ Medications compatible with trastuzumab include granisetron, diphenhydramine hydrochloride, dexamethasone sodium phosphate, calcium gluconate, magnesium sulfate, potassium chloride »» These medications may not be compatible with each other »» These medications should be in normal saline; they are not compatible in D5W ■■

• Indicated for the treatment of HER2-overexpressing breast cancer, metastatic gastric cancer, or gastroesophageal junction adenocarcinoma Mechanism of action

• Trastuzumab inhibits proliferation of tumor cells that overexpress HER2, binding specifically to extracellular domain of HER2 receptor or HER2/neu protein ——Overexpression of HER2 receptor contributes to neoplastic transformation ——HER2 receptor participates in receptor-receptor interactions that regulate cell differentiation, growth, and proliferation Dosage and administration

• Dosages ——Adjuvant treatment of HER2-overexpressing breast cancer ■■ Initial dose of 4 mg/kg over 90 minute IV infusion, then 2 mg/kg over 30 minute IV infusion weekly for 52 weeks, or ■■ Initial dose of 8 mg/kg over 90 minute IV infusion, then 6 mg/kg over 30-90 minutes IV infusion every 3 weeks for 52 weeks ——Metastatic HER2-overexpressing breast cancer ■■ Initial dose of 4 mg/kg over 90 minute IV infusion followed by subsequent weekly doses of 2 mg/kg as 30 minute IV infusion ——Metastatic HER2-overexpressing gastric cancer

Continues on page 38

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 37

STAT CONSULT Special populations

• Pregnant women ——Pregnancy category D • Nursing mothers ——Lactation ■■ Unknown whether excreted in human breast milk ■■ Discontinue breast feeding or discontinue trastuzumab Cautions

• Cardiomyopathy • Infusion reactions • Embryo-fetal toxicity • Pulmonary toxicity • Exacerbation of chemotherapy-induced neutropenia • HER2 testing should be performed using FDA-approved test by laboratories with demonstrated proficiency Adverse effects

• Adjuvant breast cancer ——Most common adverse reactions (≥5%) are headache, diarrhea, nausea, and chills • Metastatic breast cancer ——Most common adverse reactions (≥10%) are fever, chills, headache, infection, congestive heart failure, insomnia, cough, and rash • Metastatic gastric cancer ——Most common adverse reactions (≥10%) are headache, diarrhea, nausea, and chills Drug interactions

• Anthracycline antineoplastic agents ——Trastuzumab-induced cardiotoxic effects can be increased in patients receiving an anthracycline concomitantly; comcomitant use not recommended in the treatment of metastatic breast cancer • Paclitaxel ——A 1.5-fold increase in mean trough serum concentration of trastuzumab was reported in a clinical study when the drug was administered concomitantly with paclitaxel versus an anthracycline and cyclophosphamide What to tell your patient

• Trastuzumab is used by itself or with other medications to treat breast and gastric tumors that produce excess amount of the HER2 protein • This medication is a monoclonal antibody ——It attaches to the HER2 cancer cells and blocks them from dividing and growing

——It may also destroy the cancer cells directly or signal the body’s immune system to destroy the cancer cells • Side effects ——Although this medication may cause side effects, its benefit may be greater than that risk ——Many people do not have serious side effects ——Some of the side effects are: ■■ Muscle, joint, or back pain ■■ Redness at the IV site ■■ Stomach pain ■■ Trouble sleeping ■■ Diarrhea ■■ Nausea and/or vomiting ■■ Loss of appetite ——Since the nausea and vomiting can be severe, your doctor may prescribe medication to prevent or relieve it ——Tell your nurse or doctor immediately if you experience any of these unlikely but more serious side effects: ■■ Swelling, tingling or numbness in your hands, feet, ankles, or legs ■■ Trouble breathing ■■ Unusual tiredness ■■ Severe headache or dizziness ■■ Bone pain ■■ Increased coughing ■■ Changes in mood ■■ Fast or pounding heartbeat ——Seek immediate medical attention if any of these rare but very serious side effects occurs: ■■ Weakness on one side of the body ■■ Slurred speech ■■ Vision changes ■■ Confusion ——You may be able to lessen side effects by not eating before treatment, eating several small meals, or limiting your activity ——If these side effects do not go away or they get worse, tell your doctor or nurse • Pregnancy and lactation ——Advise women of childbearing potential to use effective contraceptive methods during treatment and for a minimum of 6 months following treatment ——Advise nursing mothers treated with trastuzumab to discontinue nursing or discontinue trastuzumab ——Encourage women who are exposed to trastuzumab during pregnancy to enroll in MotHER (Herceptin Pregnancy Registry) ■ Prepared and updated by Jason Hoffman, PharmD, RPh.

38 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

RADIATION & YOUR PATIENT

©ISTOCK

Digital illustration of prostate cancer

High-dose-rate brachytherapy: An option for prostate cancer Bryant Furlow High-dose-rate brachytherapy is typically used as a dose-escalating boost for external beam radiotherapy (EBRT) for prostate cancer. But some researchers believe it might be close to graduating to a viable monotherapy—an alternative, rather than an adjuvant, to prostate EBRT.

rachytherapy involves the precisely positioned implantation of short-range radioisotopecontaining beads at the sites of tumors, with little exposure of adjacent nontarget tissue to irradiation, thanks to the rapid irradiation dose fall-off. This is why prostate tumor brachytherapy is believed to allow the most conformal high dose radiotherapy possible to the prostate, sparing healthy, nontarget

tissues more effectively than can be achieved with external beam radiotherapy (EBRT).1 Brachytherapy can be delivered via two different dose-rate techniques. Low-dose rates (LDR) emit 2 Gy/hour or less from permanently implanted radioisotope seeds. In contrast, high-dose-rate (HDR) brachytherapy delivers 10 Gy/hour or more, via temporarily implanted catheters.1 Both LDR and HDR brachytherapy beads are placed under guidance of transrectal ultrasound (TRUS).1 HDR delivers a high dose over a few minutes; LDR delivers its radiation dose over weeks or months.1 LDR brachytherapy is a standard monotherapy for patients with lowto intermediate-risk prostate cancer.1 HDR brachytherapy, in contrast, has been used as a radiation dose-escalating boost to EBRT in the treatment of prostate cancer.1,2 It is the most frequently used local EBRT doseescalation technique for patients with intermediate- and high-risk prostate cancer—an approach that appears to be less toxic than dose escalations involving increased EBRT dose.1 The authors of a phase 3 randomized clinical trial found that this increasingly popular radiation dose-escalation strategy is both safe and clinically efficacious in patients with localized prostate cancer, significantly reducing the risk of tumor recurrence (by 31%; P=.01) and improving relapse-free survival times (albeit not overall survival times), compared with EBRT alone—and doing so with rates of late urinary and rectal toxicity comparable to those associated with EBRT alone.3 Authors of a 2014 systematic review of data from 14 prospective and 24 retrospective singleinstitution clinical studies of HDR brachytherapy boost for prostate cancer

similarly found encouraging rates of grade 3-4 late radiation toxicities, affecting fewer than 6% of patients overall.4 Recently, HDR brachytherapy has gained attention as a promising monotherapy alternative to EBRT, rather than an EBRT adjuvant or boost.1,5,6

High disease control rates have been reported for patients receiving HDR monotherapy. High disease control rates have been reported for patients receiving HDR monotherapy, “particularly in patients with low- and intermediate-risk disease,” note Gerard Morton, MD, of the University of Toronto in Ontario, Canada, and P.J. Hoskin, MD, of the Mount Vernon Cancer Centre, Northwood, in Middlesex, England.1 Several studies have reported biochemical relapse-free survival rates exceeding 90% for such men, they note.1 “Selected high-risk patients have also been treated with HDR monotherapy, with reported recurrence-free survival of 79% to 93%,” they note. OPTIMAL SCHEDULE REMAINS UNCLEAR

As with EBRT, HDR brachytherapy can be hypofractionated for accelerated delivery of total therapeutic dose in fewer fractions, and the published literature includes a much wider range of fraction and total doses for HDR brachytherapy than LDR.1 Continues on page 40

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 39

RADIATION & YOUR PATIENT Defi ning optimum dose fraction schedules remains a pressing challenge for proponents of HDR monotherapy, experts agree.1 But despite the wide range of radiation doses reported for HDR, most studies report similar outcomes, making it difficult to identify the best hypofractionation schedule.1,7 Older studies involved delivery of HDR brachytherapy in four to six, and as many as nine, fractions because of concern about possible toxicities arising from higher dose fractions, but Morton and Hoskin report that growing evidence exists to supports the delivery of HDR in three or even two fractions.1

Single-fraction HDR monotherapy would have considerable logistic and cost advantages over the alternatives. The two most frequently employed fractionation schedules in the published literature are 54 Gy delivered in six fractions, or 38 Gy in four fractions, according to Morton and Hoskin.1 “More recently there has been a trend of using fewer fractions, with several series reporting favorable results with the use of a single HDR dose,” they note. Single-fraction HDR

FIND US ON

monotherapy would have considerable logistic and cost advantages over the alternatives.

REFERENCES 1. Morton GC, Hoskin PJ. Brachytherapy: current status and future strategies—can high dose rate replace low dose rate and

KEYS TO TREATMENT DURATION Image guidance with TRUS guides the transperineum placement of temporary catheters at the base of the prostate, and then TRUS or an alternative imaging modality like computed tomography (CT) or magnetic resonance imaging (MRI) is used to acquire data for treatment planning. (“Computed tomography contouring of soft-tissue anatomy can be challenging, but MRI provides optimal soft-tissue imaging and definition of the clinical target volume,” Morton and Hoskin note.1 However, TRUS and CT are far more widely available than MRI, they acknowledge.) Treatment plans specify bead placement and dwell times along target tissue (tumor) contours to minimize irradiation of nearby nontarget healthy but radiosensitive rectal and urethral tissue.1 Treatment delivery usually requires about 10 minutes, but depending on imaging modalities employed, HDR brachytherapy can require 90 minutes (with TRUS) to several hours (with CT or MRI).1 If longer follow-up studies confirm the early promise of single-fraction HDR monotherapy, this may well become the treatment of choice for many men with localized prostate cancer, Morton and Hoskin predict. ■

external beam radiotherapy? Clin Oncol (R Coll Radiol). 2013;25(8):474-482. doi:10.1016/ j.clon.2013.04.009. 2. Morton G, Loblaw A, Cheung P, et al. Is single fraction 15 Gy the preferred high dose-rate brachytherapy boost dose for prostate cancer? Radiother Oncol. 2011;100(3):463-467. 3. Hoskin PJ, Rojas AM, Bownes PJ, et al. Randomised trial of external beam radiotherapy alone or combined with high-dose-rate brachytherapy boost for localized prostate cancer. Radiother Oncol. 2012;103(2):217-222. doi:10.1016/j.radonc.2012.01.007. 4. Zaorsky NG, Doyle LA, Yamoah K, et al. High dose rate brachytherapy boost for prostate cancer: a systematic review. Cancer Treat Rev. 2014;40(3):414-425. doi:10.1016/j.ctrv.2013.10.006. 5. Tselis N, Tunn UW, Chatzikonstantinou G, et al. High dose rate brachytherapy as monotherapy for localised prostate cancer: a hypofractionated two-implant approach in 351 consecutive patients. Radiat Oncol. 2013;8:115 doi:10.1186/1748717X-8-115. 6. Yoshioka Y, Konishi K, Suzuki O, et al. Monotherapeutic high-dose-rate brachytherapy for prostate cancer: a dosereduction trial. Radiother Oncol. 2014;110(1): 114-119. doi:10.1016/j.radonc.2013.10.015. 7. Yamada Y, Rogers L, Demanes DJ, et al; American Brachytherapy Society. American Brachytherapy Society consensus guidelines for high-dose-rate prostate brachytherapy.

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

Brachytherapy. 2012;11(1):20-32. doi:10.1016/ j.brachy.2011.09.008.

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40 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

Speaking without words

Ann J. Brady, MSN, RN-BC

Sylvia’s smile was ear to ear while her mother’s was a slight curl of her lips and a flash of eye contact. But it was something.

CASE

Her daughter, Sylvia, was dying from metastatic cancer. There were no words for her anguish. The fact that she did not speak English was secondary. Each time I went into the room she glared at me. I thought of her as someone from the old country and not just because she fit the picture of an old world widow—she wore a loose-fitting black dress over a sturdy frame—but because she had a severity that was palpable whenever I was near her. I suspected she had seen much in her life. Her distrust of western medicine was obvious; she did not believe her daughter was as ill as she was, nor did she embrace the notion that we knew what we were doing. Each day she occupied the same bedside chair, sitting like a guard in a gated community, gruff and dubious of all who entered. I believed I could soften her with subtle overtures—a warm smile, touching Sylvia on the arm, being extra sweet to her grandson when he visited. But I always got the same cool response and no eye contact.

I told myself not to take it personally and part of me didn’t, but another part of me felt it was very personal as she scrutinized everything I did. I was doing a good job caring for Sylvia and I wanted her mother to see it. I wanted her to trust me. When I think about Sylvia, there are many things I remember: the room she was in, the lightness in her voice, the relentless progression of her disease. Even with a memory of those small details, I realize I didn’t know her mother’s name. Not that I have forgotten her name; somehow in the course of my care of Sylvia, perhaps because of how formidable her mother was, I never stopped for the common courtesy of asking her name. After a while it was too awkward to ask, so I ended up never asking. Her silence challenged me. I wanted some acknowledgment like a nod or a smile, but I failed to make any progress. When I entered the room, she never looked up. One day Sylvia asked me, “Do you have children?” I am cautious about discussing my personal life with patients, feeling it can border on unprofessional. And, I have barriers of my own. But Sylvia’s question was direct and innocent at the same time. I answered, “I have three boys.” She smiled at me, and I was encouraged by her openness. “I call them my boys but they are all grown up. They are men really.” The words were out of my mouth before I took the time to gauge their impact. I bit my tongue. Sylvia was not going to see her son become a man. But she didn’t focus on that; instead she asked how old they were and what they were doing. She responded, “Oh, how wonderful,” when I told her. I felt guilty for reminding her that she wasn’t going to see her son grow up. Continues on page 42

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 41

COMMUNICATION CHALLENGES My communication challenge with Sylvia was more than my hope that she would forget how thoughtless I was when I spoke about my children; it was also about my failure to connect with her mother. Interestingly those two barriers were connected. The comments I made about my own family had the opposite effect from what I feared. The next time I entered the room Sylvia and her mother both looked up and smiled. Sylvia’s smile was ear to ear while her mother’s was a slight curl of her lips and a flash of eye contact. But it was something. It was more than anything so far. DISCUSSION

We never spoke, not in words we both understood. But finally, in the language of two mothers, we made a connection.

I stumbled into a relationship with Sylvia’s mother. Sometimes the barrier to establishing a therapeutic relationship is as simple as sharing how similar you are. Our role as mothers united us and made a link I had not anticipated. I was focused on my care of Sylvia, but in the process, I had essentially neglected her mother. Sharing my story gave me a place to start a relationship. When I shifted my attention from Sylvia to her mother, it was then that I recognized she was on the verge of losing her only daughter. She needed support too. Even when she failed to make eye contact or seemed to be keeping me at bay she was still losing her daughter. I took her guarded and suspicious interaction to mean disapproval of the care I gave, yet what was missing was a way for her to express herself. I had created a barrier without even realizing it by sticking to professional behavior. For

JOIN THE CONVERSATION • What strategies do you employ to connect with patients and their families when language is a barrier? • How do you develop a therapeutic relationship with patients or families who are suspicious of your care?

ON THE

WEB

Go to OncologyNurseAdvisor.com/challenges-nowords to share how you overcome communication barriers and cultural differences when interacting with patients and families.

her part, Sylvia understood how difficult it was for her mother and allowed her to be protected by a jail of her own making. It was the only way she could manage to stay at the bedside and watch as the cancer took Sylvia from her. Her mom was as much my patient as Sylvia was. The barrier she created was self-protective. It was easier to make the nurses the enemy because the real enemy was cancer and she could not beat it. Over the course of her hospitalization Sylvia engaged more fully with me. In her own way, so did her mother. She relaxed in her chair when I was talking with Sylvia, an unspoken gesture of welcome. One day as I talked with Sylvia, her mother quietly removed the seeds from a pomegranate and put them on a plate. The deep red seeds bled onto the white plate and Sylvia carefully spooned some into her mouth. She told me, “In my culture, we believe pomegranates are good for your blood. They make you strong.” I nodded in understanding. Then her mother lifted the plate to me. Sylvia said, “She wants you to have strong blood, too.” I took a spoonful, the first time I had eaten pomegranate seeds. They were sweet and delicious. When a small dribble of juice ran down my chin, I finally got the acknowledgment I wanted from her mother. She handed me a napkin and smiled. In all honesty, her mother remained suspicious, what I would call a mama bear. Even with her skepticism it was apparent that Sylvia was dying. When I hear people talk of the stages of grief I wonder how a parent ever gets past anger and denial. Maybe finding a level of acceptance of me and the hospital and western medicine was a greater leap for her mother than I realized. Maybe it was me that changed when I opened myself up to Sylvia and her mother. We never spoke, not in words we both understood. But finally, in the language of two mothers, we made a connection. ■ Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

42 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

THE ONA INTERVIEW

Educating men about prostate cancer

Genderspecific barriers and communication styles still present challenges when interacting within the health care system.

ncolog y nurses care for patients with all levels of health literacy. Some patients are content to just do what they are told. Some patients want to know everything about their disease and seek full participation in their health care decisions. The current health care climate clearly prefers, and often rewards, the latter group. Health Dialog, a wholly owned subsidiary of Rite Aid Corporation, offers products designed to help people participate in their own health care decisions, develop more effective relationships with their health care team, and live longer, healthier, happier lives. Traditionally, men are less likely to become involved in their health care and health care decision making than are women. This can manifest into a challenging situation for those who care for patients with prostate cancer. Oncology Nurse Advisor (ONA) talked to Peter Goldbach, MD, chief medical officer at Health Dialog, about encouraging men to be more informed participants in their health care decisions.

ONA: Are men more involved health care consumers compared with previous generations? GOLDBACH: Men, as well as women, are

more involved health care consumers today and for a number of reasons. People are exposed to information from many different directions such as in the media, direct-toconsumer advertising, and on the Internet. Due to advances in health care, patients have to make more decisions about tests, procedures, and treatment; however, too often patients may not know that they have choices.

Gender-specific barriers and communication styles still present challenges when interacting within the health care system. Everybody has barriers, including clinicians. Nurses need to be aware of this and should tailor discussions to the patient. Decisionmaking aids can help clinicians work more effectively with their patients. ONA: What patient-communication challenges are unique to male patients? GOLDBACH: Men’s general communication

styles persist when discussing their health care. For example, men are less likely to engage in discussions about their health with other men, or even with their family (eg, their spouses), whereas women are more likely to share information with others. In addition, women build relationships with health care providers through interactions related to reproductive health, family care, and care of elderly family members, whereas men tend to have fewer interactions with health care providers, especially in their early adulthood years. Men, for whatever reason, tend to wait longer than women before seeking attention for a health care issues. All patients can experience communication challenges when interacting with their physicians, particularly when a medical decision needs to be made. Shared decision making (SDM) is a process that helps patients be better prepared to work with their caregivers and arrive at treatment choices that better reflect their preferences and needs. SDM involves ensuring that patients are well educated about their condition and treatment options, have thought about what matters most to them in terms of treatment

www.OncologyNurseAdvisor.com • SEPTEMBER/OCTOBER 2014 • ONCOLOGY NURSE ADVISOR 43

THE ONA INTERVIEW

Patients may experience decisional conflict or feeling stuck about a health care decision and struggle to participate.

outcomes, and ensures that their preferences become part of the final treatment plan. ONA: Which types of tools are more likely to effectively encourage men to participate in their health care decision making: Web-based (independent searches or clinician-directed use), in-person meetings (one-on-one or group), or print materials? GOLDBACH: Although people can access so

much health information in today’s world, high quality information that is not tainted by commercial interests can be hard to come by. At Health Dialog, we found that the most useful tools are those endorsed by physician experts, provide unbiased and evidencebased information, are easy to understand, and feature examples of different health care decisions made by other people based on their individual situations and preferences. Barriers to access for decision-making tools must be low. The tools should be available online as well as in hard-copy booklet form, and must be easy to understand. An opportunity to engage with a health care professional such as a coach who can guide the patient through an episode of care should be part of the tools offered to patients. People do not always know they are facing a health care decision, and providers do not always have the same goals as their patients. ONA: Explain the basic concepts of shared decision making. GOLDBACH: SDM programs are designed to

ensure that patients are aware of the available options. For example, patients who have a fear of colonoscopies may not realize that other noninvasive screenings (eg, fecal occult blood test [FOBT] smear) may be an option for them. Programs can be population based (ie, for health insurance companies). In this case, these programs rely on analytics to identify patients in need and outreach programs designed to engage patients. SDM programs can also be practice based (ie, offered by the health care provider) or employer based (ie,

part of a comprehensive wellness program that promotes appropriate screenings and preventive health behaviors). ONA: How can oncology nurses identify which patients may be reluctant to participate in shared decision making? GOLDBACH: Patients may experience deci-

sional conflict or feeling stuck about a health care decision and struggle to participate. Nurses are most often the health care professional charged with identifying and engaging patients who may benefit from SDM, providing patients with decision aids, and coaching them through their decision. Identification and engagement are critical steps for any effective program. ONA: What can nurses do to encourage patients’ participation in their health care decisions? GOLDBACH: Nurses can encourage adopting

SDM programs that manage shared decision making in such a way as to ensure that it is available to all who need it. An effective program identifies the applicable patients, has a system for engaging them, measures the effectiveness of engagement, and features highly trained nurses to transfer knowledge and provide decision support. The program should be available in a way that’s convenient for patients, so after-hours options are important. Nurses can help increase patients’ confidence levels by providing decision aids that show real people who have gone through the same decision process. Nurses can help patients strategize their meetings with physicians to facilitate a more effective interaction. Achieving real results can be difficult without a true population-based program. Just presenting available content does not accomplish much; nurses need to establish a relationship with their patients in the course of providing care. Oncology nurses are known to rely on this strategy. To read the ONA Interview with Peter Goldbach in its entirety, go to www.OncologyNurseAdvisor. com/ONAinterview-Goldbach. ■

44 ONCOLOGY NURSE ADVISOR • SEPTEMBER/OCTOBER 2014 • www.OncologyNurseAdvisor.com

FROM

Animal assisted therapy enhances cancer care Erin Columbus, LCSW

As the validity of AAI as a therapeutic intervention mounts, health care institutions across the country are adopting AAI practices with great success.

nimal assisted therapy (AAT) and animal assisted activities (AAA) are quickly becoming more prevalent in the health care field due to the myriad benefits they offer patients. AAT offers a more specific therapeutic goal and intervention with the animal while AAA is more open ended, less formalized, and usually comes in the form of visitations. Animal assisted interventions (AAI) is the umbrella term used to describe these practices. As the validity of AAI as a therapeutic intervention mounts, hospitals, nursing homes, and other health care institutions across the country are adopting AAI practices with great success. Some enlist the help of organizations such as Pet Partners, The Good Dog Foundation, or Therapy Dogs International to provide dog-therapy teams for vulnerable populations. Each team includes a dog and trainer (usually the dog’s owner), both of whom have completed a comprehensive training and certification program. This process enables both dog and trainer to learn how to best communicate with one another as well as interact therapeutically with the public, and more specifically, with vulnerable populations such as the elderly, people with terminal illnesses, children, posttraumatic stress disorder (PTSD) survivors, and people with physical and mental disabilities. AAI has been instituted in several large and notable hospitals such as Memorial Sloan Kettering, Mount Sinai, New York Methodist, and New York-Presbyterian

hospitals. In May 2011, Pf izer and the American Humane Association teamed up on a research program designed to measure the impact of AAT on pediatric oncology patients as well as on their family members/ caregivers.1 This collaboration represents a significant shift in thinking, and an effort to validate that AAI programs are impactful, relevant, and efficient therapeutic practices we should consider employing in the health care/mental health field.1 In addition, many hospitals across the country have begun allowing patients’ own pets to visit while the owner is hospitalized. This practice has become popular because of the immediate and lasting benefits of being near a pet that is also an integral and beloved family member.

AI is most vital when a patient is faced with a particularly scary, vulnerable, or life-threatening situation. The presence of a warm and accepting creature can provide a sense of security, comfort, and love that can help patients to heal more quickly. The benefits of interacting with a dog (or other domesticated animal) have been well documented; it can reduce blood pressure; ease stress, anxiety, and depression; relieve pain; and contribute to an overall sense of well being. Biologically speaking, domesticated animals are an essential part of our evolution as human beings, and for thousands of years have provided safety, companionship, and comfort as our brains confronted survival dilemmas. This has inextricably linked us

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nteracting with a dog also offers an opportunity to relate to others, creating feelings of trust and therefore enabling staff members and patients to engage in therapeutic relationships more readily. For example, an extensive study of the use of dogs in therapy in North America, funded by Alberta Health’s innovation fund, compared animal assisted therapy with traditional therapy for patients in treatment for depression and anxiety.4 The patients who met with therapists who used dogs in their sessions looked forward to therapy more, felt more comfortable talking to the therapist, and felt they performed better at home and school than patients receiving traditional therapy. Pet ownership on its own seemed to moderate the effects of mental illness. Patients who had pets were less depressed or anxious at the outset

and showed lower scores on the depression severity scale after therapy compared with those who did not own pets.4

here are also direct physical and strength-building benefits to AAI. Dogs need activity, and this need can be an impetus for patients to engage in exercise alongside the dog, an often much-needed aspect of holistic patient care. For patients who are hospitalized or institutionalized for long periods of time, the risk of depression, anxiety, and isolation becomes much more prevalent. Visiting with an animal can stave off the negative aspects of living in an unnaturally sterile environment; it can reconnect them to the world outside, to nature, and to life itself. The presence of a loving, warm, and accepting creature can create a deep sense of connection, healing, and hope amidst a very difficult time and is an invaluable aspect of patient care and quality of life. ■ Erin Columbus is clinical supervisor/program director of Online Services at CancerCare. REFERENCES 1. Pfizer Animal Health and American Humane Association partner to conduct research on the power of the human-animal bond in pediatric cancer patients [news release]. American Humane Association Web site. http://www.american humane.org/animals/animal-welfare-news/pfizeranimal-health-and-american-humane-association. html. Accessed September 9, 2014. 2. Johnson RA. Editorial: Human-animal interaction, illness prevention, and wellness promotion. Am Behav Sci. 2003;47(1):5-6. 3. Johnson RA, Meadows RL, Haubner JS, Sevedge K. Human-animal interaction: a complementary/ alternative medical (CAM) intervention for cancer patients. Am Behav Sci. 2003;47(1):55-69. 4. Dobbs BM. The Chimo Project—improving mental health through animal assisted therapy: Independent evaluator’s final report. http://www. angelfire.com/mh/chimo/pdf/Chimo-Final_ReportRevised.pdf. Accessed September 9, 2014.

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©THINKSTOCK

as a species to our animal counterparts and helps us to tap into a different part of our brains, thereby enabling us to let down our defenses. A study conducted by Rebecca Johnson, PhD, RN, of the University of Missouri-Columbia Center for the Study of Animal Wellness, showed that when a human pets a dog, within minutes they experience a massive release of beneficial hormones known to be associated with health and feelings of well-being, such as beta endorphin, prolactin, dopamine, oxytocin, and beta phenylethylamine.2,3 Interacting with an animal also reduces the presence of the stress hormone cortisol, enabling people to better cope with stressful and anxiety-provoking situations. This research is welcome news for those with compromised immune systems and pain due to cancer and its treatments. Not only is AAI a cost-effective and powerful therapeutic intervention, but it can help patients in unexpected ways. The simple act of petting a dog distracts patients from their own internal experience, enabling their physical, emotional, and spiritual pain to take a back seat for those few precious moments. Focusing on something outside of oneself provides a sense of connection and meaning.

The simple act of petting a dog distracts patients from their own internal experience.

ISSUES IN CANCER SURVIVORSHIP Camp Dream Street provides a summertime staple for kids with cancer Bette Weinstein Kaplan

ippy, a French bulldog, was excited as we drove through the beautiful grounds of the community center where the day camp was in session. Two large areas were blocked off from cars, and I had to park some distance away from the camp, so I put the little dog into his cart and off we went to find Camp Dream Street. Camp Dream Street is a camp for children with cancer, blood disorders, and other often life-threatening illnesses sponsored by the Dream Street Foundation. The foundation supports camps in several locations throughout the United States. Although most of the camps are the sleep-away kind, Zippy and I were visiting a Dream Street day camp in New Jersey whose administrators appreciate the healing power of therapy dogs. They invite a number of dog-and-handler teams to the campus every day during the weeklong session. Zippy, a survivor himself, was unable to walk when he was rescued. After undergoing back surgery, physical therapy, and acupuncture, he made a significant recovery and is now a certified therapy dog. The wheeled cart—some people call it a doggie wheelchair—supports his pelvis and abdomen when he has to walk a distance, making ambulation less stressful on his vulnerable back and hindquarters. A visit from a therapy dog with

his own disability really heightens the experience for people with serious health problems. The children at Camp Dream Street play with the therapy dogs, read to them, tell them their secrets, and help their

Co-founder Billy Grubman explains, “We give them the chance to do what they want to do. What other kids do.” handlers exercise them. Some youngsters even make that camp classic, the lanyard, for a favorite therapy dog. It is a mutually enjoyable form of therapy. And that is why we went to Camp Dream Street. A CHANCE TO BE A KID The mission of Camp Dream Street is to enable children with cancer and other diseases to enjoy activities that might otherwise be unavailable to them. There is an unusually high counselorto-camper ratio and a full-time medical staff at each location. Medical trailers function as mini hospitals where nurses and doctors administer IVs and other medication; no one misses a treatment.

Theatrical producer Patty Grubman and her brother, Billy Grubman, founded the all-volunteer Dream Street Foundation in 1988. Its sleepaway camps are often held in cooperation with luxury venues such as Canyon Ranch resorts, thus providing ideal locations. Currently, there are camps in Arizona, Arkansas, California, and Mississippi, as well as the camp I was visiting in New Jersey. The first Camp Dream Street, held in California in 1988, hosted 42 campers. Today, more than 750 children and adolescents age 4 to 24 years from throughout the United States and other countries attend the camp sessions each summer, at no cost to them or their families. Many campers are from low-income families. The foundation also provides air transportation free of charge when necessary. YOUNG ADULTS, TOO Older campers are welcome at the camp at Canyon Ranch in Tucson, Arizona, which hosts young adults age 17 to 21 years. The structure for these young people is somewhat different. These campers are in the throes of adolescence; therefore, in addition to offering camping activities and medical care, there is an emphasis on helping them deal with age-appropriate issues such as anger, family dynamics, self-image, and peer pressure. Continues on page 49

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THE TOTAL PATIENT

Evidence-based design: A new concept in health care facilities that puts the focus on patients Bette Weinstein Kaplan

recent article in The New York Times discussed the benefits derived from creating hospital rooms that are more patient friendly.1 When it was time to redesign and expand their hospital in 2003, the management team of the University Medical Center of Princeton at Plainsboro [New Jersey] (UMPCC) did their homework. They studied evidence-based design and new concepts in hospital architecture.2 They surveyed staff and patients. They tested the designs and survey results by creating a simulated patient room in the existing hospital, complete with furniture and medical equipment. Nurses and doctors provided input from the actual room, discussing the placement of everything from handrails along the wall to locating the scrub sink in view of the patient. THE PATIENTS’ INPUT At the completion of that phase, the room was ready for use. Over the next few months, patients who had undergone orthopedic surgery did their postoperative recuperation in the model room. The patients liked having amenities such as a desk and individual temperature controls they could operate, and their guests appreciated having a family zone with two chairs and a sofa bed. The testers found the room to be quiet and enjoyed its view of the

outdoors. Compared with patients in the old hospital rooms, those in the model room perceived their nursing care and food to be better, even though these were identical in both rooms. The newly designed room demon-

Studies demonstrate that if patients are in an environment designed to reduce their stress and pain, it usually does. strated its clinical advantage when the patients who stayed in it required 30% less analgesic medication than those in the old rooms.1-3 After almost 10 years and $523 million, the new 636,000-square-foot hospital opened in 2012, and all 221 patient rooms were versions of the model room. The management team had obviously done their homework well. The same-handed (not mirror image) design encourages privacy and quiet. The singlebed rooms and emphasis on hygiene ensure that incidences of patient falls and infections remain dramatically lower in the new building, and the patient satisfaction rating is almost 100%.1,3

THE SUNLIGHT EFFECT Part of the reason patients at UMPCC required less pain medication may have been the positive effect of sunlight coming through large windows. A prospective study of 89 surgical patients supports this theory.4 The investigators wrote, “Our aim was to evaluate whether the amount of sunlight in a hospital room modifies a patient’s psychosocial health, the quantity of analgesic medication used, and the pain medication cost.”4 The investigators placed patients in rooms on one of two sides of the hospital according to the amount of light that filtered into the rooms. Rooms on the “bright side” of the building had an average 46% higher intensity of light than those on the “dim side.” Patients in the brighter, which received a higher intensity of sunlight, rooms reported having less stress and less pain and required 22% less pain medication per hour than those patients in rooms on the dim side of the hospital.4 In a paper exploring the inf luence of environmental stimuli on pain, Malenbaum and colleagues noted that patients with pain are rarely in an interesting or relaxing environment. “The typical treatment room is painted white, lacking decoration, sparsely furnished, and windowless. Patient’s auditory stimuli may range from the noise generated by overhead lighting to urgent, loud paging requests to sounds of other patients

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suffering.”5 However, as many studies demonstrate, if patients are given an environment designed to reduce their stress and pain, it usually does. The authors suggest that changes can be effected without expensive redesign. For example, put patients who are experiencing the most pain in those rooms with the most windows and the nicest views. The authors note that both natural and artificial light, as well as views of unspectacular nature, has positive effects on pain and mood.5 EVIDENCE-BASED DESIGN

Evidence-based design is defined as “the deliberate attempt to base health care building design decisions on best available evidence,” explained Roger S. Ulrich, PhD, the leading proponent of the concept.6 Ulrich is professor of architecture at the Center for Healthcare Building Research at Chalmers University of Technology in Gothenburg, Sweden, and adjunct professor of architecture at Aalborg University in Denmark. He

Survivorship Continued from page 47

One camper said, “You feel surrounded by people who understand, who care. It’s excellent. They make you feel like you’re important.” Dream Street co-founder Billy Grubman explains, “They’ve got a disease they don’t want, treatment they hate. It’s painful. … We free them from that. We give them the chance to do what they want to do. What other kids do.”1 JUST LIKE EVERYONE ELSE

The camps offer normal camping activities such as arts and crafts, swimming, and horseback riding—with volunteers

is internationally the most frequently cited researcher of evidence-based health care design, and his design principles have contributed to more than 1,200 buildings that heal, including the University Medical Center of Princeton at Plainsboro.6 Ulrich founded the Center for Health Design to educate and certify health and design professionals in the principles of evidence-based design. As part of that, the Pebble Project, a unique and dynamic collaborative that intends to create a ripple effect in the health care community, offers education, membership, and recognition for creators of innovative healing environments.6 ■

REFERENCES 1. Kimmelman M. In redesigned room, hospital patients may feel better already. The New York Times. August 21, 2014. http://nyti. ms/1tmIpkQ. Accessed September 12, 2014. 2. Rabner BS. How to help hospitals achieve their mission through good design. HERD. 2012;5(3):7-11. 3. University Medical Center of Princeton at Plainsboro. http://www.princetonhcs.org/ phcs-home/what-we-do/universitymedical-center-of-princeton-at-plainsboro. aspx. Accessed September 12, 2014. 4. Walch JM, Rabin BS, Day R, et al. The effect of sunlight on postoperative analgesic medication use: a prospective study of patients undergoing spinal surgery. Psychosom Med. 2005;67(1):156-163.

On the Web The online version of this article includes a link to an interactive view of a patient room at University Medical Center of Princeton at Plainsboro.

5. Malenbaum S, Keefe FJ, Williams AC, et al.

Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.

6. Pebble Project. https://www.healthdesign.

to accompany them and help as needed. For one camper, being in the water with the assistance of her counselors meant that she was able to stand for the first time in years.2 Counselors also help campers lift weights, dance, even zoom along on a zip line. They hold dog shows, carnivals, acrobatic performances, barbecues, and dances. It’s a full week, crammed with pleasant things for a change. Many campers do so well that they come back each summer, and some even go on to become counselors. As one camper wrote in a thank you letter to Canyon Ranch and Dream Street, “In the past seven days I have done so much more than I ever thought myself capable of that it has been almost like I’ve been given my body back.”2

For more about Camp Dream Street, visit www.dreamstreetfoundation.org. ■

Pain in its environmental context: implications for designing environments to enhance pain control. Pain. 2008;134(3):241-244. org/pebble. Accessed September 12, 2014.

Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCES 1. Fedunak S. Empathy specialty of Dream Street [The Arizona Daily Star]. Dream Street Foundation Web site. http://www. dreamstreetfoundation.org/docs/p007amedia-001-arizona-daily-star.pdf. Accessed September 5, 2014. 2. Braunstein M. Dreams of a Dream Street Camper [Canyon Ranch Roundup]. Dream Street Foundation Web site. http://www. dreamstreetfoundation.org/docs/p007amedia-003-canyon-ranch-roundup.pdf. Accessed September 5, 2014.

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REFLECTIONS

Maureen Timony, RN

Three hundred children ran down the hill to welcome us. What an amazing experience that was.

magine seeing all the amazing colors of Earth in one place. Visualize vivid green grass in the morning that turns to a profound deep green in the early evening before sunset, and shades of brown and beige with hues of orange throughout on the horizon. In addition to the breathtaking landscape, seeing countless zebras with finely detailed black and white stripes and giraffes with shades of brown and white spots, all within the eye’s view. This was not a ride in Disneyland but a ride in a large van carrying nurses, physicians, and ancillary staff to a small village outside Nairobi, Kenya. Here, I share with you the beginning of my nursing work in Africa. The Maywood [New Jersey] Rotary Club sponsors an elementary school in a small village in Kenya, providing items such as school supplies, uniforms, and daily lunches. Bigger projects included building new classrooms, installing fences around the school buildings to protect the children and staff from wild animals, and constructing a mile-long pipeline from an underground spring to the school that delivers fresh, clean water to the children and surrounding community.

s to be expected, I was both nervous and excited about the mission trip. One of the hardest parts was the grueling travel. The trip to Kenya begins with two very long flights—New York to Dubai, United Arab Emirates, and then on to Nairobi. Nairobi can be compared to New York City, albeit a severely impoverished version. Diesel is the only fuel, and the exhaust causes thick air congestion. There are no traffic lights and only a few stop signs, which appear

to be ignored. I was amazed there were not more traffic accidents. After our team arrived at the Nairobi airport, we climbed into a van that took us to the campsite—a 4-hour ride over unpaved roads. Once out of the city, we saw some residential sections with beautiful homes in gated communities. After passing these sections, all that was visible were the spectacular African Plains. After traveling for 2 hours, the van pulled over so we could view the Great African Rift, a grand valley whose beauty could not be captured with a camera. Surrounded by mountains on all sides, words cannot fully describe its magnificent beauty.

will never forget my first experience with the children in the village. The number of children in the pre-K and kindergarten class overwhelmed me; more than 40 children were crowded into the classroom with only one teacher. As the grades advanced, however, the number of children in the classrooms declined. Some children were forced to stay home and work, some of the girls—some as young as 10 to 12 years old—were married off in exchange for cows and goats, and many children died from malaria and other preventable diseases. My initial reaction to the children was horror; I was not prepared to see mucus of all colors pouring from their eyes, noses, and ears and flies burrowed in the mucus. Most of the children did not have shoes, and their hands, feet, and clothes were filthy. Many had shaking chills and high fevers as well as sclera jaundice. The scene was extremely traumatic for me especially as I work in a bone marrow transplant unit, a place where no one is allowed access with even a trace

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of the common cold let alone any kind of infectious process. I felt so torn, so guilty. These innocent, poverty-stricken children wanted to be held, and I was afraid of touching them and of them touching me. Nothing could have prepared me for the state of these children, and I could not wait to leave and go back to the camp. As I walked back to the camp, I could not get over what I had just witnessed. At dinner, I couldn’t eat. How could I when I knew the only meal those children had had that day was lunch? How could children who appear so sick seem to enjoy life so much, evident by their smiling, playing, and singing? I had 4 more days to make a difference, and I knew that I had to change my frame of mind.

he next morning, as we set back out to the village, I felt a change come over me. As we approached the entrance gate, a small child who was looking out for us ran to tell the others that we were coming. Three hundred children ran down the hill to welcome us. What an amazing experience that was. Ten children were holding onto my 10 fingers on the walk back up the hill while singing a welcome song, and my co-volunteers had 10 children each holding their fingers, too. Suddenly, I no longer felt threatened by the dirt, runny noses, and coughs. A colleague, who had pediatric experience, and I assessed various ailments such as ringworm, eye infections, cuts, and bruises in more than 300 children over the next 4 days. Our makeshift clinic consisted of a classroom with a broken desk and buckets of water that the children brought from the river. Our first project was to teach hand washing. Some of these children had never seen soap. By the end of the demonstration, the children had suds all over their bodies and hair and were squealing with delight. In addition to hand washing, we taught first aid to the upper classmen and teachers.

hat journey changed me in so many ways, both in nursing and in my personal life. I have shared my experiences in Africa with many patients who were anxious about their upcoming transplant. In one case, I had a patient who panicked, stating, “I am not moving forward with transplant” and started to pack up to leave the unit. I had my photo album with me, and I said to her, “Before you leave, would you like to go on a safari with me and see the people and animals of Africa?” We sat together as I described my experience. By the time we were done, she was ready to start her stem cell transplant. I found that sharing my photos and stories with patients and their family members provided a distraction, placed them at ease, and helped to build a relationship of trust and compassion. Those children gave me so much more than I could ever have given them. They showed me how to appreciate all I have in life and made me realize how much I have taken for granted. They taught me a world without prejudice as they laughed with merriment when they could not rub my “white” off. They demonstrated the true meaning of sharing as I watched so many children play with one soccer ball and never once fight over it. They imparted unconditional love by appreciating everything I did for them, even if all I did was wipe their runny noses. I feel blessed to have been a part of such a great project. The smiles, gratitude, laughter, songs, and love from this community were priceless. The sights and colors of Africa, especially standing in a field at night under the Milky Way as it lit the trees or sitting in an open jeep surrounded by thousands of animals were breathtaking experiences. I hope to go back many more times and help the Maasai children have a safe and healthier life. ■

I found that sharing my photos and stories with patients and their family members helped to build a relationship of trust and compassion.

Maureen Timony is a bone marrow transplant/ apheresis nurse in the Transplant Division at John Theurer Cancer Center at Hackensack University Medical Center in Hackensack, New Jersey.

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ASK A PHARMACIST

Reconstituting nab-paclitaxel; managing irritation from fosaprepitant Is there a good reason to mix nabpaclitaxel (Abraxane) with warm (not cool) normal saline when reconstituting? —Name withheld on request

Nab-paclitaxel is an albumin-bound formulation of paclitaxel. It is supplied commercially as a sterile powder that must be reconstituted using normal saline for injection (0.9% sodium chloride). Due to the formulation of this product, there are strict temperature requirements. Unopened vials should be stored at controlled room temperature (68°-77° F). If the reconstituted vial is not used immediately, it may be stored for up to 8 hours under refrigerated conditions (36°-46° F). Once prepared for administration (ie, in an

infusion bag), the product is stable only for up to 4 hours. Warming saline prior to reconstituting nab-paclitaxel is not recommended. Because the paclitaxel is contained within albumin particles, the reconstitution instructions and temperature parameters described in the product prescribing information should be followed closely. Once the product is warmed or cooled beyond the parameters specified in the prescribing information, the product viability and potency can no longer be guaranteed since the albumin particles may have denatured. This could potentially affect the efficacy and toxicity of nab-paclitaxel therapy. Parenteral fosaprepitant (Emend) has the potential to cause venous irritation. What are best practices to reduce venous irritation and delayed irritation? Is the drug an irritant or vesicant? If the drug infiltrates, what is the management?

been reported in approximately 3% of patients receiving fosaprepitant. Injection site reactions may include infusion site erythema, pruritis, pain, induration, and thrombophlebitis. Patients experiencing venous irritation should be counseled regarding care for the site as appropriate per the patient’s symptoms. In patients experiencing irritation, it may be helpful to administer a more dilute form of the drug for future doses. For instance, fosaprepitant may be diluted to a final volume of 250 mL, or may be administered through a Y-site with additional saline. If fosaprepitant infiltrates, the infusion should be stopped immediately. The infiltration should be managed per your organization’s standard procedure for managing infiltration of a nonvesicant, nonirritant drug, based on patient symptoms and the estimated volume that may have infiltrated.

—Name withheld on request

DEA RULING NOW IN EFFECT Reclassification of hydrocodone products to schedule II

Fosaprepitant is a prodrug of aprepitant (Emend), a neurokinin (NK1) antagonist used for the prevention of chemotherapy-induced nausea and vomiting, that may be administered intravenously. Once in the body, fosaprepitant is rapidly converted to aprepitant. Injection site reactions (including phlebitis) have

In August of this year, the DEA reclassified hydrocodone combination products from a schedule III to a schedule II substance. This new rule becomes effective on October 6, 2014. Prescriptions issued on or after this date may not be written with refills and must follow the laws for prescribing of other CII substances. ■

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

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