Ocotober 2012, Vol 3, No 5

OCTOBER 2012

www.AONNonline.org

VOL 3, NO 5

CLINICAL PRACTICE The Impact of Nurse Navigation on the Patient Experience

MEASURING OUTCOMES Patient Navigation: Defining Metrics That Support and Justify the Nurse Navigator Position

REVIEW ARTICLE Helping Your Patients Manage ChemotherapyInduced Nausea and Vomiting

TM

NAVIGATING PATIENTS ACROSS THE CONTINUUM OF CANCER CARE

Š 2012 Green Hill Healthcare Communications, LLC

The median age of patients in the VISTA‥ trial was 71 years (range: 48-91).

VISIT US AT THE 2012 ADVANCED CONTENT CONFERENCE TO LEARN MORE

Survival nnever ever ggets ets oold ld VELCADE® (bortezomib) delivered >13-month overall survival advantage in combination with MP* vs MP alone for previouslyy untreated multiple myeloma (median 56.4 vs 43.1 months†; 60.1-month median follow-up‡)

Approved for subcutaneous and IV administration§ VELCADE (bortezomib) Indication ication and Important Safety Information INDICATION nt of patients

CONTRAINDICATIONS sensitivity to ndicated for

WARNINGS, PRECAUTIONS, AND DRUG INTERACTIONS ▼

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may occur – on. Patients eated with ment ng patients y of syncope,

▼

existing

▼ ▼

been reported ve occurred heal

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omplete blood ut treatment

▼ Women should avoid becoming pregnant while being treated with VELCADE (bortezomib). Pregnant women should be apprised of the potential harm to the fetus ▼ Closely monitor patients receiving VELCADE in combination with strong CYP3A4 inhibitors. Concomitant use of strong CYP3A4 inducers is not recommended

ADVERSE REACTIONS Most commonly reported adverse reactions (incidence ≥30%) in clinical studies include asthenic conditions, diarrhea, nausea, constipation, peripheral neuropathy, vomiting, pyrexia, thrombocytopenia, psychiatric disorders, anorexia and decreased appetite, neutropenia, neuralgia, leukopenia, and anemia. Other adverse reactions, including serious adverse reactions, have been reported

Please see Brief Summary for VELCADE on next page. *Melphalan+prednisone. † HR=0.695 (95% CI, 0.57-0.85); p<0.05. < ‡ VISTTA: a randomized, open-label, international t phase 3 trial (N=682) evaluating t the efficacy and safety of VELCADE administered intravenously enously in combinattion with MP vs MP in previously untreatted multiple myeloma (MM). The primary endpoint was TTPP. Secondary endpoints were CR, ORR, PFS, and overall survival. At a pre-specified interim analysis (median follow-up 16.3 months), VELCADE+MP resulted in significantly superior results for TTP (median 20.7 months with VELCADE+MP vs 15.0 months with MP [p=0.000002]), PFS, overall survival, and ORR. Further receiving MP were offered ther enrollment was halted and patients t re VELCADE in addition. Updatted analyses were performed. § The reconstituted uted concentrattion for subcutaneous administra nistraation tion (2.5 mg/mL) is greaater than the t reconstituted concentration t for IV administra inistrattion (1 mg/mL).

▼ patic Failure

Living Proof

Brief Summary INDICATIONS: VELCADE® (bortezomib) for Injection is indicated for the treatment of patients with multiple myeloma.

VELCADE is indicated for the treatment of patients with mantle cell lymphoma who have received at least 1 prior therapy.

CONTRAINDICATIONS: VELCADE is contraindicated in patients with hypersensitivity to bortezomib, boron, or mannitol.

VELCADE is contraindicated for intrathecal administration.

WARNINGS AND PRECAUTIONS: VELCADE should be administered under the supervision of a physician experienced in the use of antineoplastic therapy. Complete blood counts (CBC) should be monitored frequently during treatment with VELCADE. Peripheral Neuropathy: VELCADE treatment causes a peripheral neuropathy that is predominantly sensory. However, cases of severe sensory and motor peripheral neuropathy have been reported.

Patients with pre-existing symptoms (numbness, pain or a burning feeling in the feet or hands) and/or signs of peripheral neuropathy may experience worsening peripheral neuropathy (including ≥ Grade 3) during treatment with VELCADE. Patients should be monitored for symptoms of neuropathy, such as a burning sensation, hyperesthesia, hypoesthesia, paresthesia, discomfort, neuropathic pain or weakness. In the Phase 3 relapsed multiple myeloma trial comparing VELCADE subcutaneous vs. intravenous the incidence of Grade ≥ 2 peripheral neuropathy events was 24% for subcutaneous and 41% for intravenous. Grade ≥ 3 peripheral neuropathy occurred in 6% of patients in the subcutaneous treatment group, compared with 16% in the intravenous treatment group. Starting VELCADE subcutaneously may be considered for patients with pre-existing or at high risk of peripheral neuropathy.

Patients experiencing new or worsening peripheral neuropathy during VELCADE therapy may benefit from a decrease in the dose and/or a less dose-intense schedule. In the single agent phase 3 relapsed multiple myeloma study of VELCADE vs. Dexamethasone following dose adjustments, improvement in or resolution of peripheral neuropathy was reported in 51% of patients with ≥ Grade 2 peripheral neuropathy in the relapsed multiple myeloma study. Improvement in or resolution of peripheral neuropathy was reported in 73% of patients who discontinued due to Grade 2 neuropathy or who had ≥ Grade 3 peripheral neuropathy in the phase 2 multiple myeloma studies. The long-term outcome of peripheral neuropathy has not been studied in mantle cell lymphoma.

Hypotension: The incidence of hypotension (postural, orthostatic, and hypotension NOS) was 13%. These events are observed throughout therapy. Caution should be used when treating patients with a history of syncope, patients receiving medications known to be associated with hypotension, and patients who are dehydrated. Management of orthostatic/postural hypotension may include adjustment of antihypertensive medications, hydration, and administration of mineralocorticoids and/or sympathomimetics.

Cardiac Disorders: Acute development or exacerbation of congestive heart failure and new onset of decreased left ventricular ejection fraction have been reported, including reports in patients with no risk factors for decreased left ventricular ejection fraction. Patients with risk factors for, or existing heart disease should be closely monitored. In the relapsed multiple myeloma study of VELCADE vs. dexamethasone, the incidence of any treatment-emergent cardiac disorder was 15% and 13% in the VELCADE and dexamethasone groups, respectively. The incidence of heart failure events (acute pulmonary edema, cardiac failure, congestive cardiac failure, cardiogenic shock, pulmonary edema) was similar in the VELCADE and dexamethasone groups, 5% and 4%, respectively. There have been isolated cases of QT-interval prolongation in clinical studies; causality has not been established.

Pulmonary Disorders: There have been reports of acute diffuse infiltrative pulmonary disease of unknown etiology such as pneumonitis, interstitial pneumonia, lung infiltration and Acute Respiratory Distress Syndrome (ARDS) in patients receiving VELCADE. Some of these events have been fatal. In a clinical trial, the first two patients given high-dose cytarabine (2 g/m2 per day) by continuous infusion with daunorubicin and VELCADE for relapsed acute myelogenous leukemia died of ARDS early in the course of therapy. There have been reports of pulmonary hypertension associated with VELCADE administration in the absence of left heart failure or significant pulmonary disease. In the event of new or worsening cardiopulmonary symptoms, a prompt comprehensive diagnostic evaluation should be conducted.

Reversible Posterior Leukoencephalopathy Syndrome (RPLS): There have been reports of RPLS in patients receiving VELCADE. RPLS is a rare, reversible, neurological disorder which can present with seizure, hypertension, headache, lethargy, confusion, blindness, and other visual and neurological disturbances. Brain imaging, preferably MRI (Magnetic Resonance Imaging), is used to confirm the diagnosis. In patients developing RPLS, discontinue VELCADE. The safety of reinitiating VELCADE therapy in patients previously experiencing RPLS is not known.

Gastrointestinal Adverse Events: VELCADE treatment can cause nausea, diarrhea, constipation, and vomiting sometimes requiring use of antiemetic and antidiarrheal medications. Ileus can occur. Fluid and electrolyte replacement should be administered to prevent dehydration.

Thrombocytopenia/Neutropenia: VELCADE is associated with thrombocytopenia and neutropenia that follow a cyclical pattern with nadirs occurring following the last dose of each cycle and typically recovering prior to initiation of the subsequent cycle. The cyclical pattern of platelet and neutrophil decreases and recovery remained consistent over the 8 cycles of twice weekly dosing, and there was no evidence of cumulative thrombocytopenia or neutropenia.

The mean platelet count nadir measured was approximately 40% of baseline. The severity of thrombocytopenia was related to pretreatment platelet count. In the relapsed multiple myeloma study of VELCADE vs. dexamethasone, the incidence of significant bleeding events (≥Grade 3) was similar on both the VELCADE (4%) and dexamethasone (5%) arms. Platelet counts should be monitored prior to each dose of VELCADE. Patients experiencing thrombocytopenia may require change in the dose and schedule of VELCADE. There have been reports of gastrointestinal and intracerebral hemorrhage in association with VELCADE. Transfusions may be considered. The incidence of febrile neutropenia was <1%.

Tumor Lysis Syndrome: Because VELCADE is a cytotoxic agent and can rapidly kill malignant cells, the complications of tumor lysis syndrome may occur. Patients at risk of tumor lysis syndrome are those with high tumor burden prior to treatment. These patients should be monitored closely and appropriate precautions taken.

Hepatic Events: Cases of acute liver failure have been reported in patients receiving multiple concomitant medications and with serious underlying medical conditions. Other reported hepatic events include increases in liver enzymes, hyperbilirubinemia, and hepatitis. Such changes may be reversible upon discontinuation of VELCADE. There is limited re-challenge information in these patients.

Hepatic Impairment: Bortezomib is metabolized by liver enzymes. Bortezomib exposure is increased in patients with moderate or severe hepatic impairment; these patients should be treated with VELCADE at reduced starting doses and closely monitored for toxicities.

Use in Pregnancy: Pregnancy Category D. Women of childbearing potential should avoid becoming pregnant while being treated with VELCADE. Bortezomib administered to rabbits during organogenesis at a dose approximately 0.5 times the clinical dose of 1.3 mg/m2 based on body surface area caused post-implantation loss and a decreased number of live fetuses.

ADVERSE EVENT DATA: Safety data from phase 2 and 3 studies of single-agent VELCADE (bortezomib) 1.3 mg/m2/dose administered intravenously twice weekly for 2 weeks followed by a 10-day rest period in 1163 patients with previously treated multiple myeloma (N=1008, not including the phase 3, VELCADE plus DOXIL® [doxorubicin HCI liposome injection] study) and previously treated mantle cell lymphoma (N=155) were integrated and tabulated. In these studies, the safety profile of VELCADE was similar in patients with multiple myeloma and mantle cell lymphoma.

In the integrated analysis, the most commonly reported adverse events were asthenic conditions (including fatigue, malaise, and weakness); (64%), nausea (55%), diarrhea (52%), constipation (41%), peripheral neuropathy NEC (including peripheral sensory neuropathy and peripheral neuropathy aggravated); (39%), thrombocytopenia and appetite decreased (including anorexia); (each 36%), pyrexia (34%), vomiting (33%), anemia (29%), edema (23%), headache, paresthesia and dysesthesia (each 22%), dyspnea (21%), cough and insomnia (each 20%), rash (18%), arthralgia (17%), neutropenia and dizziness (excluding vertigo); (each 17%), pain in limb and abdominal pain (each 15%), bone pain (14%), back pain and hypotension (each 13%), herpes zoster, nasopharyngitis, upper respiratory tract infection, myalgia and pneumonia (each 12%), muscle cramps (11%), and dehydration and anxiety (each 10%).

Twenty percent (20%) of patients experienced at least 1 episode of ≥Grade 4 toxicity, most commonly thrombocytopenia (5%) and neutropenia (3%). A total of 50% of patients experienced serious adverse events (SAEs) during the studies. The most commonly reported SAEs included pneumonia (7%), pyrexia (6%), diarrhea (5%), vomiting (4%), and nausea, dehydration, dyspnea and thrombocytopenia (each 3%).

In the phase 3 VELCADE + melphalan and prednisone study in previously untreated multiple myeloma, the safety profile of VELCADE administered intravenously in combination with melphalan/prednisone is consistent with the known safety profiles of both VELCADE and melphalan/prednisone. The most commonly reported adverse events in this study (VELCADE+melphalan/prednisone vs melphalan/prednisone) were thrombocytopenia (52% vs 47%), neutropenia (49% vs 46%), nausea (48% vs 28%), peripheral neuropathy (47% vs 5%), diarrhea (46% vs 17%), anemia (43% vs 55%), constipation (37% vs 16%), neuralgia (36% vs 1%), leukopenia (33% vs 30%), vomiting (33% vs 16%), pyrexia (29% vs 19%), fatigue (29% vs 26%), lymphopenia (24% vs 17%), anorexia (23% vs 10%), asthenia (21% vs 18%), cough (21% vs 13%), insomnia (20% vs 13%), edema peripheral (20% vs 10%), rash (19% vs 7%), back pain (17% vs 18%), pneumonia (16% vs 11%), dizziness (16% vs 11%), dyspnea (15% vs 13%), headache (14% vs 10%), pain in extremity (14% vs 9%), abdominal pain (14% vs 7%), paresthesia (13% vs 4%), herpes zoster (13% vs 4%), bronchitis (13% vs 8%), hypokalemia (13% vs 7%), hypertension (13% vs 7%), abdominal pain upper (12% vs 9%), hypotension (12% vs 3%), dyspepsia (11% vs 7%), nasopharyngitis (11% vs 8%), bone pain (11% vs 10%), arthralgia (11% vs 15%) and pruritus (10% vs 5%).

In the phase 3 VELCADE subcutaneous vs. intravenous study in relapsed multiple myeloma, safety data were similar between the two treatment groups. The most commonly reported adverse events in this study were peripheral neuropathy NEC (38% vs 53%), anemia (36% vs 35%), thrombocytopenia (35% vs 36%), neutropenia (29% vs 27%), diarrhea (24% vs 36%), neuralgia (24% vs 23%), leukopenia (20% vs 22%), pyrexia (19% vs 16%), nausea (18% vs 19%), asthenia (16% vs 19%), weight decreased (15% vs 3%), constipation (14% vs 15%), back pain (14% vs 11%), fatigue (12% vs 20%), vomiting (12% vs 16%), insomnia (12% vs 11%), herpes zoster (11% vs 9%), decreased appetite (10% vs 9%), hypertension (10% vs 4%), dyspnea (7% vs 12%), pain in extremities (5% vs 11%), abdominal pain and headache (each 3% vs 11%), abdominal pain upper (2% vs 11%). The incidence of serious adverse events was similar for the subcutaneous treatment group (36%) and the intravenous treatment group (35%). The most commonly reported SAEs were pneumonia (6%) and pyrexia (3%) in the subcutaneous treatment group and pneumonia (7%), diarrhea (4%), peripheral sensory neuropathy (3%) and renal failure (3%) in the intravenous treatment group.

DRUG INTERACTIONS: Bortezomib is a substrate of cytochrome P450 enzyme 3A4, 2C19 and 1A2. Co-administration of ketoconazole, a strong CYP3A4 inhibitor, increased the exposure of bortezomib by 35% in 12 patients. Therefore, patients should be closely monitored when given bortezomib in combination with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir). Co-administration of omeprazole, a strong inhibitor of CYP2C19, had no effect on the exposure of bortezomib in 17 patients. Co-administration of rifampin, a strong CYP3A4 inducer, is expected to decrease the exposure of bortezomib by at least 45%. Because the drug interaction study (n=6) was not designed to exert the maximum effect of rifampin on bortezomib PK, decreases greater than 45% may occur. Efficacy may be reduced when VELCADE is used in combination with strong CYP3A4 inducers; therefore, concomitant use of strong CYP3A4 inducers is not recommended in patients receiving VELCADE. St. John’s Wort (Hypericum perforatum) may decrease bortezomib exposure unpredictably and should be avoided. Co-administration of dexamethasone, a weak CYP3A4 inducer, had no effect on the exposure of bortezomib in 7 patients. Co-administration of melphalan-prednisone increased the exposure of bortezomib by 17% in 21 patients.

However, this increase is unlikely to be clinically relevant.

USE IN SPECIFIC POPULATIONS: Nursing Mothers: It is not known whether bortezomib is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from VELCADE, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use: The safety and effectiveness of VELCADE in children has not been established.

Geriatric Use: No overall differences in safety or effectiveness were observed between patients ≥age 65 and younger patients receiving VELCADE; but greater sensitivity of some older individuals cannot be ruled out.

Patients with Renal Impairment: The pharmacokinetics of VELCADE are not influenced by the degree of renal impairment. Therefore, dosing adjustments of VELCADE are not necessary for patients with renal insufficiency. Since dialysis may reduce VELCADE concentrations, VELCADE should be administered after the dialysis procedure. For information concerning dosing of melphalan in patients with renal impairment, see manufacturer’s prescribing information.

Patients with Hepatic Impairment: The exposure of bortezomib is increased in patients with moderate and severe hepatic impairment. Starting dose should be reduced in those patients.

Patients with Diabetes: During clinical trials, hypoglycemia and hyperglycemia were reported in diabetic patients receiving oral hypoglycemics. Patients on oral antidiabetic agents receiving VELCADE treatment may require close monitoring of their blood glucose levels and adjustment of the dose of their antidiabetic medication.

Please see full Prescribing Information for VELCADE at VELCADEHCP.com.

VELCADE, MILLENNIUM and are registered trademarks of Millennium Pharmaceuticals, Inc. Other trademarks are property of their respective owners.

Millennium Pharmaceuticals, Inc., Cambridge, MA 02139 Copyright © 2012, Millennium Pharmaceuticals, Inc. All rights reserved.

Printed in USA

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Letters from LILLIe

Editor-in-Chief Lillie D. Shockney, RN, BS, MAS University Distinguished Service Associate Professor of Breast Cancer Depts of Surgery and Oncology Administrative Director, Johns Hopkins Breast Clinical Programs Administrative Director, Johns Hopkins Cancer Survivorship Programs Associate Professor, JHU School of Medicine, Depts of Surgery & Gynecology and Obstetrics Associate Professor, JHU School of Nursing

AONN MOVING FORWARD Dear Colleague,

I

want to begin by telling all of you how honored and proud I am to have been asked to serve as the Program Director for the Academy of Oncology Nurse Navigators (AONN). I am a strong advocate of navigation and survivorship and know that we can provide the educational content, networking, and career development you need and deserve as we move AONN forward. In the coming months and years, we will continue to focus on your needs and those of the patients you diligently navigate across the continuum of care.

What a treat for me, immediately following the announcement of my new role for the organization, to then hold our 3rd annual AONN conference! More than 400 attendees came together in Phoenix for the purpose of empowering themselves with even more knowledge—knowledge communicated by an amazing lineup of expert speakers from around the country. The feedback I personally received was incredible, with comments such as “this is the best conference I have ever attended” and “how did you manage to recruit such top-notch speakers providing content that is all new and so valuable for us to learn?” And this is only the beginning! We are already working on the agenda for our 4th annual conference, which will take place in mid November 2013 in Memphis. The content will be very much driven by the survey feedback we received (and who knows—Elvis might be in the building!).

But AONN is not just about holding a stellar annual conference. We are committed to providing educational forums throughout the year, in this journal and in blogs online, which will be renamed “expert commentary” to more accurately reflect the content and its value for all of us. In addition, webinars will be created for you throughout the year on topics that are critically important for you to be aware of and learn about—and that can directly aid you in the wonderful work you do.

AONN and the leadership and staff that make everything happen on your behalf want to ensure that we are providing you value with your membership. So, anticipate receiving in the coming months notifications about new Web site interactive features, the creation of virtual interest groups on specialty areas (like specific organ-site cancers, such as breast cancer), phases of navigation and survivorship (ie, surgical management, community outreach, survivorship care plans), and about the extensive work on our end to create a robust resource database that will provide access to special resources for patients being navigated and supported by an AONN member.

Enjoy reading the synopsis of our most recent conference, in case you missed it, and mark your calendars for our meeting in Memphis in 2013! g With kind regards,

shockli@jhmi.edu

Section Editors Breast Cancer Sharon Gentry, RN, MSN, AOCN, CBCN Breast Health Navigator Derrick L. Davis Forsyth Regional Cancer Center

Prostate Cancer Frank delaRama, RN, MS, AOCNS Clinical Nurse Specialist Oncology/Genomics Cancer Care Clinic Palo Alto Medical Foundation

Healthcare Disparities Linda Fleisher, PhD, MPH Assistant Vice President Office of Health Communications & Health Disparities Assistant Professor Cancer Prevention & Control Fox Chase Cancer Center

Health Promotion and Outreach Iyaad Majed Hasan, MSN, FNP Director and Nurse Practitioner Survivorship Clinic and Program Cleveland Clinic Taussig Cancer Center

AONN Research Committee Marcy Poletti, RN, MSN Program Administrator, Oncology Services Wake Forest University Baptist Medical Center

Elaine Sein, RN, BSN, OCN, CBCN Senior Project Manager Fox Chase Cancer Center Partners

Penny Widmaier, RN, MSN Nurse Navigator Botsford Cancer Center

MISSION STATEMENT

The Journal of Oncology Navigation & Survivorship (JONS) promotes reliance on evidence-based practices in navigating patients with cancer and their caregivers through diagnosis, treatment, and survivorship. JONS also seeks to strengthen the role of nurse and patient navigators in cancer care by serving as a platform for these professionals to disseminate original research findings, exchange best practices, and find support for their growing community.

Lillie D. Shockney, RN, BS, MAS Editor-in-Chief

AONNONLINE.ORG

JOURNAL OF ONCOLOGY NAVIGATION & SURVIVORSHIP

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PUBLISHING STAFF SENIOR VICE PRESIDENT, SALES & MARKETING

Philip Pawelko phil@greenhillhc.com PUBLISHER

John W. Hennessy john@greenhillhc.com DIRECTOR, CLIENT SERVICES

Eric Iannaccone eric@greenhillhc.com EDITORIAL DIRECTOR

Kristin Siyahian kristin@greenhillhc.com

TABLE OF CONTENTS

OCTOBER 2012 • VOL 3, NO 5

MANAGING EDITOR

Jim Scelfo jim@greenhillhc.com EDITORIAL ASSISTANT

Jennifer Brandt

CLINICAL PRACTICE

10

SENIOR COPY EDITOR

The Impact of Nurse Navigation on the Patient Experience

By Jean A. McDonald, RN, MS; Patty Abella, RN, BSN

Rosemary Hansen PRODUCTION MANAGER

Stephanie Laudien QUALITY CONTROL DIRECTOR

Barbara Marino

MEASURING OUTCOMES

16

BUSINESS MANAGER

Blanche Marchitto

Patient Navigation: Defining Metrics That Support and Justify the Nurse Navigator Position

By Ana Rosa Espinosa, DNP, MBA, RN, OCN; Molly Gabel, MD;

CIRCULATION DEPARTMENT

Pamela Vlahakis, RN, MSN, CBCN

circulation@greenhillhc.com Journal of Oncology Navigation & Survivorship, ISSN 21660999 (print); ISSN 2166-0980 (online), is published 6 times a year by Green Hill Healthcare Communications, LLC, 1249 South River Road, Suite 202A, Cranbury, NJ 08512.

Telephone: 732.656.7935. Fax: 732.656.7938. Copyright ©2012 by Green Hill Healthcare Communications, LLC. All rights reserved. Journal of Oncology Navigation & Survivorship logo is a registered trademark of Green Hill Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any informational storage and retrieval system, without written permission from the publisher. Printed in the United States of America.

EDITORIAL CORRESPONDENCE should be addressed to MANAGING EDITOR, Journal of Oncology Navigation & Survivorship (JONS), 1249 South River Road, Suite 202A, Cranbury, NJ 08512. E-mail: jim@greenhill hc.com. YEARLY SUBSCRIPTION RATES: United States and possessions: individuals, $50.00; institutions, $90.00; single issues, $5.00. Orders will be billed at individual rate until proof of status is confirmed. Prices are subject to change without notice. Correspondence regarding permission to reprint all or part of any article published in this journal should be addressed to REPRINT PERMISSIONS DEPARTMENT, Green Hill Healthcare Communications, LLC, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. The ideas and opinions expressed in JONS do not necessarily reflect those of the editorial board, the editorial director, or the publisher. Publication of an advertisement or other product mention in JONS should not be construed as an endorsement of the product or the manufacturer’s claims. Readers are encouraged to contact the manufacturer with questions about the features or limitations of the products mentioned. Neither the editorial board nor the publisher assumes any responsibility for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this periodical. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosage, the method and duration of administration, or contraindications. It is the responsibility of the treating physician or other healthcare professional, relying on independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient.

Every effort has been made to check generic and trade names, and to verify dosages. The ultimate responsibility, however, lies with the prescribing physician. Please convey any errors to the editorial director.

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OCTOBER 2012 • VOLUME 3, ISSUE 5

REVIEW ARTICLE

22

Helping Your Patients Manage Chemotherapy-Induced Nausea and Vomiting

By Rosalie Canosa, LCSW-R; Sharon Gentry, RN, MSN, AOCN, CBCN

Correction: In the list of authors of the abstract “Role of Navigation and Patient Education in the Treatment of Patients With Complex Cancers: Our Experience With Head and Neck Cancer Patients,” published in our August issue, Jacqueline MacLasco's degrees were misidentified. The correct listing is: Jacqueline MacLasco, RD, CDN. ABOUT THE COVER My Despair, My Hope Acrylic by a Person Diagnosed With Cancer, Indiana I’ve always been the type of person who sees the glass half-full, but in the face of cancer, the emotional tug-of-war seems endless.

There is despair, after learning I have cancer. There is hope, knowing I will fight and do whatever is necessary to defeat this.

There is despair, because so much is unknown, so much is uncertain.

But, there is hope, in the embrace of my family and friends, whose love and support gives me strength.

Yet, now there is only hope. No other word encompasses all that I feel today.

AONNONLINE.ORG

VELCADE and Millennium are registered trademarks of Millennium Pharmaceuticals, Inc. Other trademarks are property of their respective owners. *The VELCADE Reimbursement Assistance Program does not file claims or appeal claims for callers, nor can it guarantee that you will be successful in obtaining reimbursement

Millennium Pharmaceuticals, Inc., Cambridge, MA 02139 Copyright Š 2010, Millennium Pharmaceuticals, Inc. All rights reserved.

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www.CutaneousMalignancies.com

SAVE THE DATE • JULY 26-28, 2013 SECOND ANNUAL

CONFERENCE CO-CHAIRS SANJIV S. AGARWALA, MD Professor of Medicine Temple University School of Medicine Chief, Oncology & Hematology St. Luke’s Cancer Center Bethlehem, PA STEVEN J. O’DAY, MD Hematology/Oncology Director of Clinical Research Director of Los Angeles Skin Cancer Institute at Beverly Hills Cancer Center Clinical Associate Professor of Medicine USC Keck School of Medicine Adjunct Faculty, John Wayne Cancer Institute Beverly Hills, CA AXEL HAUSCHILD, MD Professor of Dermatology Department of Dermatology University of Kiel Kiel, Germany

Melanoma • Basal Cell Carcinoma • Cutaneous T-Cell Lymphoma Squamous Cell Carcinoma • Merkel Cell Carcinoma

July 26-28, 2013 Hyatt Regency La Jolla at Aventine 3777 La Jolla Village Drive San Diego, California

www.CutaneousMalignancies.com

Overview

INTRODUCTION Authors respond to challenges posed at “Best Practices in Oncology Nurse Navigation” Conference

I

n February 2012, MindStream Education1 held a conference in Orlando, Florida, titled “Best Practices in Oncology Nurse Navigation.” The conference was co-chaired by Lillie Shockney, RN, BS, MAS, a professor at Johns Hopkins who is also the Director of the Johns Hopkins Clinical Breast Programs and Survivorship Programs as well as editor-in-chief of the Journal of Oncology Navigation & Survivorship (JONS) and Program Director for the Academy of Oncology Nurse Navigators (AONN), and Julie Silver, MD, a physician from Harvard Medical School who is an assistant professor in the Department of Physical Medicine and Rehabilitation. There were approximately 200 participants, including primarily oncology nurse navigators; however, physicians, administrators, and oncology social workers also attended.

The focus of the conference was to highlight the modern trend of oncology nurse navigation by presenting pioneering strategies and best practice case studies from leading healthcare organizations. The large attendance reflects the desire for information about nursing navigation as well as the need for greater knowledge about program leadership and the operations of oncology services. In a rousing brainstorming episode, Dr Silver led an interactive think-tank session in which all participants shared ideas on improving current navigation processes and care services for cancer patients in order to provide the highest quality of patient care. She challenged the group to develop a strategy, using concrete evidence including outcomes, to convince their administration that navigation is a critical part of oncology care. A volunteer group of conference participants, several of whom had expertise in academic publishing, teamed up to write the outcome of the discussions and captured the following topics of discussion: • What is the role of an oncology nurse navigator?

• What barriers does an oncology nurse navigator encounter?

AONNONLINE.ORG

• What strategies are or can be used to overcome the barriers?

• What are ways to track outcomes/metrics and have them support or justify the oncology nurse navigator role?

• Are there other means to justify the oncology nurse navigator job?

The 4 articles generated by the ideas from this conference are ones that the authors hope will provide insight on developing, maintaining, and improving nurse navigation programs. Each arti-

Dr Silver led an interactive think-tank session in which all participants shared ideas on improving current navigation processes and care services... cle is intended to assist programs in deciphering what they need in order to move their navigation program forward, incorporate best practices of navigation from leading healthcare organizations, and stimulate conversations among the disciplines that support navigation programs to ensure that navigation is included in the delivery of quality cancer care.

The first 2 of these articles are included in this issue of JONS, and the others are slated to run in an upcoming issue of JONS. Thanks to the authors for their initiative and efforts in putting this together. g

REFERENCE 1. Best Practices for Oncology Nurse Navigation Leadership Spring Session, February 16-17, Orlando, FL. MindStream Education Web site. www.mindstreamedu.com/past-conferencepages/nn1/. Accessed October 8, 2012.

The authors of the following 2 articles would like to express a special thank you to Dr Julie Silver for the challenge she presented and for her support during the manuscript production.

JOURNAL OF ONCOLOGY NAVIGATION & SURVIVORSHIP

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CLINICAL PrACtICe

THE IMPACT OF NURSE NAVIGATION ON THE PATIENT EXPERIENCE

By Jean A. McDonald, RN, MS ProHealth Care, Waukesha, Wisconsin

Patty Abella, RN, BSN Aurora Health Care, West Allis, Wisconsin

W

Jean A. McDonald, RN, MS

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e recognize that a diagnosis of cancer can be a life-changing event, with the journey from diagnosis to survivorship, and perhaps to end-of-life care, filled with fear, challenges, and uncertainties.1-3 The value of patient navigation provided by a highly experienced, knowledgeable, and compassionate oncology nurse can best be described by sharing comments and stories from patients who were fortunate to have been connected with a cancer nurse navigator (CNN) as their cancer journey began.4-6 Being connected to and supported by a CNN when newly diagnosed with cancer creates for the patients and families a profound sense of security and safety and helps to decrease fears and anxiety, thus allowing patients to effectively hear and process the tremendous amount of information coming at them.2,3 Informed and personalized decision making becomes more comfortable as the CNN begins to outline what patients may experience as well as serve as their guide to support their unique journey. Having a CNN shepherding a patient’s care across the continuum using the clinical expertise embedded in an evidence-based nursing practice is paramount to assure excellence in service and to optimize a patient-centered experience.1,7-9 We all know that long after treatment is completed, and again as cancer survivors’ care is ongoing, patients remember how we treated them, how we made them feel, and how we treated their family and/or loved ones. Imagine the sense of comfort that patients treasure, knowing that they are personally connected to a CNN who, as their comments illustrate, made their experience so memorable, an experience that will

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not be forgotten. Because this experience and connection were so powerful, one can reasonably assume that patients realized a deeper and more meaningful sense of hope and healing, enabling them to move forward with living beyond cancer, always mindful that the connection with the CNN would continue. The CNN is readily available and will, at defined intervals, follow up to address the patients’ needs and concerns and provide encouragement to optimize whole-person well-being.

The literature is robust in outlining the definition and value of providing patient-centered care.10,11 Likewise, most, if not all, healthcare organizations today tout a care model that embodies patient-centered care. Interestingly, when reviewing what organizations define as patient-centered care, there is some consistency; however, most often significant variation exists, which likely results in patients having a different experience depending upon where their care was provided and by whom.

A nurse navigation program has the potential to be recognized as the hallmark model for patient-centered care. The principles of patientcentered care as outlined in 1993 by Gertels and colleagues10 and in 2001 by the Institute of Medicine4 are embodied in a nurse navigation program. CNNs partner with patients and families through the care continuum, respect and honor patients’ values and preferences, coordinate and integrate care, provide information and education, ensure that communication is seamless, evaluate and intervene to provide physical comfort and emotional support, and coordinate care transitions and continuity of care.

To ensure this patient-centered care model is

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provided consistently to every patient regardless of where navigation begins, it is imperative to standardize the role of the CNN, with a consistent job description, standards, competencies, and educational preparation.12 The intent of standardizing the CNN role is to define an evidencebased model with the most important dimensions of care outlined in the framework to ensure that patients are evaluated consistently for care needs that the evidence has identified as making a difference. Key dimensions of care, including patient education, advocacy, identifying and removing barriers, psychosocial management, and navigating and coordinating care across the continuum, have an impact on patient outcomes.

The intended outcomes can be measured with confidence and validity only when the navigator’s role and key interventions are provided to every patient regardless of disease state. The degree of care is dependent upon the individual needs of the patient and family, with the CNN having the expertise to assess and plan the care needs accordingly. By having a consistent framework, organizations can measure, quantify, and validate the impact of the navigation program.

Data that demonstrate return on investment speak to administrators. We are aware that administrators support navigation programs in theory; however, they are aware that these programs are expensive and must be justified, thus the need to drive consistency in practice.

As reiterated in recent literature, the variance in navigation programs and lack of standardized procedures continue to challenge researchers in this field of study. Identifying key components relevant to effective navigation programs is essential.13 There is also a gap in comparing patient outcomes prospectively between patients who do use navigation services and those who do not use or have access to navigation services.

Again, this has merit only if variance in the role is eliminated.12,13 Likewise, nursing clinical practice must be evidence based, with a clearly defined and outcome-driven, measurable clinical pathway. Data must include patient satisfaction and, more importantly, quality-of-life (QOL) outcomes due to the interventions of the CNN. Using a tool such as the National Comprehensive Cancer Network distress thermometer to evaluate distress at defined intervals would be invaluable in identifying patient stressors that need to be man-

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aged to impact QOL positively and ensure whole-person care.3,14,15 By being standardized and evidence based, the navigation model will accelerate in terms of need and demand for the following reasons.

Patients today are seeking out cancer programs with CNNs because they have heard from family or friends or perhaps on the program’s Web site about the role of the CNN, and they want to have a navigator with them to support and coordinate all aspects of their care. As administrators want to differentiate their cancer programs from competitors, grateful and loyal patients singing the praises of the CNNs will result in increased administrative support for a navigation model. Second, a consistent navigation model will support excellence in the

We are aware that administrators support navigation programs in theory; however, they are aware that these programs are expensive and must be justified... patient-centered experience and could serve as the prototype of coordination for accountable care expectations. Finally, cancer care accrediting bodies such as the Commission on Cancer are incorporating standards that outline expectations for patient navigation.7 In the Cancer Program Standards for 2012, standard 3.1 outlines expectations for the patient navigation process. This standard must be fully implemented and will be surveyed in 2015. By providing standardized, evidence-based care, organizations will satisfy the accreditation requirements, most likely with commendation.

Ever mindful of the resource challenges we are all facing, grateful patients oftentimes become generous donors to an organization’s foundation.

Cancer patients often wish to “give back,” and do so in many ways, eg, volunteering or serving on a patient advisory council. Many times we miss a golden opportunity to ask for a charitable donation to the foundation as tribute to the excellent cancer care received because of the CNN. We also have the opportunity to share patient stories that will touch the hearts of those who may not

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have been touched by cancer personally but wish to become a donor to support a navigation program because of the positive impact it has on patients and families.

Patient stories and comments are powerful and compel us to pursue the development of navigation programs. The following story, titled “The Nurse and the Navigator: I Should Have Known,” was written by a breast cancer survivor.

The story captures poignantly the sole purpose this paper is intended to convey: every patient deserves to experience a patient navigation pro-

gram, through a consistent, standardized, evidence-based clinical practice, delivered by an experienced, knowledgeable, and compassionate oncology nurse. As you read this story, take note of how the author describes the soul-touching difference in her experience because of the CNN and the care team. I have read her story many times, and each time my emotions are triggered in yet another way that draws me to the absolute reason we need to have navigation programs in every cancer program, to best serve the patient in providing whole-person care.

The Nurse and the Navigator: I Should Have Known You see, I should have known. I’m a nurse and worked with cancer nurse navigators. I should have known. Here is my story.

On a fateful Friday afternoon, Dr W., a radiologist, saw me after a second mammogram and asked if I wanted to do an ultrasound with biopsy that very afternoon because he wanted more information about what he saw on the mammogram. I wasn’t particularly alarmed because with a history of fibrocystic breast disease and many negative aspirations, I merely thought this would be another procedure that would turn out negative. However, I watched his eyes and the monitors and saw the expression in his eyes change as the big black spots appeared on the screen. I knew that something was amiss.

As he took the biopsies from the middle of the blackness, my thoughts began to turn to the possibility that I soon could be one of those 1 of 8 women who have the diagnosis of breast cancer sometime in their lifetime. He asked if I wanted to be called on Saturday when the information came in or wait until Monday. Of course I opted for Saturday.

My husband had no idea of what had been happening that afternoon. When I recounted the events, I concluded with, “I won’t be surprised if the diagnosis is cancer when Dr W. calls tomorrow.”

The call came at 8:30 Saturday morning. Dr W.’s message was, “I have some good news and some bad news. Which do you want to hear first?” I opted for the bad news, which was that the biopsy was positive for cancer. I honestly have no memory of what the good news was. I couldn’t hear over the roar of the diagnosis of

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cancer. He said he’d contact Dr K., a breast surgeon, and I could talk with her immediately about treatment options. I thanked him, held myself together until I could hang up, and then my husband and I hugged and cried.

Immediately I went into my denial mode, thinking that of course it was detected early because I’ve had regular mammograms, and everything would be simple.

By Monday, I was driven to get the treatment started immediately. I called the only person I knew who could help me, Jean McD, Director of Cancer Services, and told her I was coming to see Dr K., the breast surgeon, immediately.

Jean asked about setting me up with a cancer navigator and I said absolutely No!! I wanted to see the surgeon TODAY, and I wanted to get treatment started immediately. Jean knew just what to say to me, and what to do. While I was driving to the Women’s Center, I was trying so hard to say the words “I have cancer” out loud, without crying. I knew I needed to hold myself together to talk to people and to get help. I yelled, whispered, hit the steering wheel, and probably scared off drivers on 94 West who had to assume the woman in that car was crazy. And they would have been right!

When I got to the Women’s Center, Pam L., a cancer nurse navigator (CNN), intercepted me, took me back to her office, and began to scrape me off the walls and ceiling to talk with me about my findings and possible interventions. Pam magically found 2½ hours to be with me that day to talk through what the journey could be like and what I needed to know to take the first baby steps. At no time did Pam

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ever get flustered, or act as if she had anything else to do that day. She was interrupted, exited for a few minutes, and came back, as if I were the only patient in the world that day. Her knowledge of cancer and of how she could best handle me and my reaction was so calming and caring. At the end, she asked if I needed to see Dr K. that day or Tuesday. Dr K. was at another hospital but would come over later in the afternoon to see me if I couldn’t wait until Tuesday.

I opted for Tuesday, because I was in a good space after talking with Pam, and she had given me lots of things to think about to organize my questions when I met with Dr K. the next day.

I should have known. As a nurse, I should have known that nurses are there to do the caring and the physical/psychosocial support, and to educate patients so they can better care for themselves. I did know that; but in my drive to quickly get this destructive creature out of my breast as soon as possible, I wanted to see the surgeon and get moving. Pam, as a trained CNN, very gently and calmly took me under her wing and started to navigate the journey with me, as a partner. I was a much more organized and calm patient when I met with Dr K. the next day. Pam created this sense of empowerment in me that, yes, I could get through this, and she would be there as my advocate every step of the journey.

But it didn’t stop there. I was not an easy patient. Life was very complicated for me at this time, and I had no time for cancer to appear in my life. Our granddaughter was going to be born in 3 weeks. I was leaving my position and interviewing for another. And somehow, pre-op procedures, surgery, and treatment had to be shoehorned between many unchangeable commitments. Dr K. gave my scheduling problems to Pam to solve, and she solved them efficiently and always with a smile. Pam was there for my lumpectomy and subsequent mastectomy, and she listened as I complained continually about my drains!

My journey ended up being not as simple as I had told myself it would be that first weekend after Dr W. had given me the diagnosis. For example, the lumpectomy found more cancer that hadn’t shown up on the diagnostic testing, more lymph glands were involved than initially

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thought, and the final blow was that, after the second elective mastectomy, cancer cells showed up in the pathology report in spite of 12 weeks of chemotherapy. Pam was there for me through all of these developments. Sometimes she would call me first and let me know the unexpected results the day before I met with Dr K. Other times, Dr K. called first, followed by a phone call from Pam to make sure I understood and to help plan the next steps. Chemo had some unexpected turns. Pam was always there checking on me and working with Dr Q., a medical oncologist, and the nurses in the infusion center just as she did when surgery was the primary treatment. And she followed me through radiation. If I had faced all these unexpected outcomes alone without Pam as my navigator, I promise you I would have been over-

As a nurse, I should have known that nurses are there to do the caring and the physical/ psychosocial support... whelmed with stress and would have come through this journey traumatized and discouraged. Today I am stable, happy, and full of gratitude for my luck in having a navigator to truly lead me through this experience.

And now that I’m through the 11-month journey, Pam and Dr K. are now starting a program for survivors to help people like me attend to the hard work of life after treatment. Dr N., my radiation oncologist, once said to me that the hardest parts of the journey are when you get the diagnosis and when the treatment ends.

I am assured now that I won’t be dropped, that I will have a navigator with me for this next chapter in the journey, and that I will be a better person for this.

My sorrow comes from knowing that not all patients have access to this level of care and navigation. Thanks to Jean McD, the Director of Cancer Services, I found Pam immediately.

Other patients are picked up after surgery, or when they are in an acute crisis. I know that

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there are not enough Pams for everyone to be helped at the very beginning of treatment, but there should be. It is only right that everyone who goes through this journey have access immediately to the careful planning, advocacy, and organization that a navigator can provide.

Physicians can’t do this work alone. It takes a village. It’s been beautiful to watch the intimate teamwork that Pam and the physicians draw on to coordinate, guide, and navigate patients through the long months of treatment

In summary, a diagnosis of cancer can be a time of transformation for a patient and her family.

Supporting this challenging transformation, a cancer nurse navigation program will balance the art and science of patient-centered care to ensure a sense of hope, healing, and security regardless of the outcome. g Disclosures: Jean A. McDonald, RN, MS, has no conflict of interest or financial interest to disclose. Patty Abella, RN, BSN, has no conflict of interest or financial interest to disclose.

REFERENCES

1. Navigating difficult waters: the history of the patient navigators. American Cancer Society Web site. http://www.can cer.org/Cancer/news/Features/navigating-difficultwaters-thehistory-of-the-patient-navigators. April 14, 2009. Accessed September 30, 2012.

2. Campbell C, Craig J, Eggert J, et al. Implementing and measuring the impact of patient navigation at a comprehensive community cancer center. Oncol Nurs Forum. 2010;37(1):61-68.

3. Dohan D, Schrag D. Using navigators to improve care of underserved patients: current practices and approaches. Cancer.

2005;104(4):848-855.

4. Institute of Medicine. Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

and survivorship.

I should have known. I’m a nurse and know what beautiful work nurses can do. But in my distress, I just wanted to see Dr K. immediately to get surgery scheduled. I didn’t know all the presurgical procedures that were necessary. I now know firsthand the beautiful work that Pam and other nurse navigators can provide to patients. I am a stronger person today because Pam was there. If she were not there, I would have fared much less well. I should have known!

5. Koh C, Nelson JM, Cook PF. Evaluation of a patient navigation program. Clin J Oncol Nurs. 2011;15(1):41-48.

6. Mandelblatt JS, Yabroff KR, Kerner JF. Equitable access to cancer services: a review of barriers to quality care. Cancer.

1999;86(11):2378-2390.

7. Commission on Cancer. Cancer program standards 2012: ensuring patient-centered care. Standard 3.1 Patient navigation process.

American College of Surgeons Web site. www.facs.org/cancer /coc/programstandards2012.pdf. Accessed September 29, 2012.

8. Fillion L, de Serres M, Cook S, et al. Professional patient navigation in head and neck cancer. Semin Oncol Nurs. 2009; 25(3):212-221.

9. Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Practice. 1995;3(1):19-30.

10. Gertels M, Edgman-Levitah S, Daley J, et al, eds. Through the Patient’s Eyes, Understanding and Promoting Patient-Centered Care. San Francisco, CA: Jossey-Bass; 1993.

11. Hegel MT, Moore CP, Collins ED, et al. Distress, psychiatric syndromes, and impairment of function in women with newly diagnosed breast cancer. Cancer. 2006;107(12):2924-2931.

12. Hook A, Ware L, Siler B, et al. Breast cancer navigation and patient satisfaction: exploring a community-based patient navigation model in a rural setting. Oncol Nurs Forum. 2012; 39(4):379-385.

13. Moore S. Making room at the table. Oncol Nurs Forum.

2010;37(1):9.

14. Swanson J, Koch L. The role of the oncology nurse navigator in distress management of adult inpatients with cancer: a retrospective study. Oncol Nurs Forum. 2010;37(1):69-76.

15. Whelan TJ, Mohide EA, Willan AR, et al. The supportive care needs of newly diagnosed cancer patients attending a regional cancer center. Cancer. 1997;80(8):1518-1524.

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Patient Navigation: Defining Metrics That Support and Justify the Nurse Navigator Position

By Ana Rosa Espinosa, DNP, MBA, RN, OCN University of Miami School of Nursing and Health Studies, Miami, Florida

Molly Gabel, MD The Cancer Institute of New Jersey/Robert Wood Johnson University Hospital, New Brunswick, New Jersey

Pamela Vlahakis, RN, MSN, CBCN Hunterdon Regional Cancer Center, Flemington, New Jersey

P

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atient navigation emerged 2 decades ago, with numerous articles reporting cancer care outcomes from the patient perspective, but its effect on improving organizational outcomes requires further research.1 However, according to data from the Oncology Roundtable’s Member Survey,2 almost 90% of cancer programs employ at least 1 full-time equivalent navigator, and many employ more than one.

Patient navigation incurs an initial economic burden from (1) fixed costs: program development, policies, procedures, office space and furnishings, and patient materials; (2) indirect costs: telecommunication, data collection and processing, program expenses related to patient-assistance activities, electronic forwarding of medical records, copies of imaging studies provided in a transportable format; and (3) human resources: employment (volunteer vs paid employee, clinical navigator vs lay navigator, full-time vs part-time navigation), training (at orientation and continuing education), and supervisory/administrative costs.3 Patient navigation also involves direct medical costs (patient charges that can be tracked through billing for prevention, screening, diagnostics, treatment, survivorship, and surveillance care); nonmedical costs such as transportation and help with childcare; and indirect costs attributable to mortality/morbidity and loss of job or reduced work productivity by the patient, friends, and/or family.3 Before 2010, the primary motivations for employing navigators were to enhance patient service, remove barriers to care, and improve care coordination. However, in 2010, the Commission on Cancer codified the importance of navigation by adding the provision of navigation services to its standards for cancer program accreditation, Standard 3.1: “A patient navigation process, driven by a community needs assessment, is established

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addressing health care disparities and barriers to care for patients. Resources to address identified barriers may be provided either on site or by referral to community-based or national organizations.”4 As a result, interest and investment in this service are expected to grow.

Achieving patient-centered, high-quality cancer care is difficult to justify when time and money are required for services that are not directly reimbursable.5 Common programmatic errors include utilizing navigators to band-aid ineffective processes, hiring staff without clearly defining organizational needs, and not having an identified system to track navigation revenue related to navigation services.2 The Patient-Reported Outcomes Working Group convened by the American Cancer Society’s National Patient Navigator Leadership Summit defined core measures to guide research and programmatic evaluation. Demonstrating significant economic and clinical values is necessary to advance patient navigation programs.3 One of the most challenging aspects of managing a navigation program is designing a method for measuring the impact of navigation services. The metrics most commonly used to monitor navigation include the number of patients receiving navigation services, overall patient satisfaction scores, and timeliness of care indicators. While each of these measures is potentially useful, none speaks to the unique value that navigators add; rather, all of them measure aspects of patient care.2 Having clearly defined goals and a measure of baseline performance for each key metric would be ideal.

Selecting the appropriate measures can be difficult but must be completed and refined before starting the process of collecting data.

WHAT IS IMPORTANT TO PATIENTS? • An integrative and compassionate approach • A relationship of trust; knowing that someone

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they trust will carry them throughout this journey • Access to care in an efficient time frame • Appropriate referral networks, including appropriate referral pathways • Coordination of services throughout the continuum of care • Assistance with obtaining medical records • Individualized prescreening for potential clinical trials • Coordination of all appointments, eg, radiation, chemotherapy • Education that is relevant to their disease processes/treatments • Individual support for their family members • Access to additional services, including nutritional counseling, psychosocial counseling, complementary medicine, and educational and nursing care services, and assistance in working with community organizations Patients and families tell us countless times how much the patient navigator helped. We, as navigators, help maintain the patient’s sense of control during a very stressful time by providing information, paving the way with appointment scheduling, answering questions that our patients may have, and providing a consistent point of contact for our patients throughout their cancer treatment and afterwards.

However, as care providers, we are also responsible for frequently evaluating our care programs using objective outcome metrics. Taking a targeted approach is important to definitively proving the value of the navigation program. By completing these evaluations, we not only make informed decisions regarding program design but we also can provide our administration with the objective data needed to support us.

MEASURING OUTCOMES OF PROGRAMMATIC SUCCESS When choosing the data to prove a point, also look at the literature and speak to administrators at your institution. Using terms or measures that the healthcare industry can understand will make your job easier. Validating your data is important, as this will help build a program that your patients, your institution, accreditation bodies, and insurance providers will value. Simplify the data collection to look at 1 or 2 prenavigation and postnavigation program data points. Each one selected should, on its own, prove beyond a

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doubt that the navigation program is responsible for the improvement.

QUESTIONS TO POSE WHEN CHOOSING OUTCOME METRICS When meeting the needs of the patient, will my work increase patient volume and/or revenue at the hospital?

• Limit the use of satisfaction surveys to navigator-specific patient satisfaction tools and use data from the survey not only to assess patient satisfaction but also to identify opportunities to refine your navigation program.

• When analyzing how your patient navigation program will increase revenue for the hospital: – Measure out-migration of patients by including a question on your baseline survey and all current program surveys. Many patients leave the system to seek second opinions because they do not have a person who will

However, as care providers, we are also responsible for frequently evaluating our care programs using objective outcome metrics. assist with making a decision or while navigating through the many treatments and procedures, thus making a difference in the patient experience. Responses that differ from the presence of a navigation program will help you elucidate that factor.

– Do not track the distance from the patient’s residence to the facility (patients vary greatly in their willingness to travel for care, and these data are not easily translatable to different regions of the country).

– Do not simply track referral patterns for all referring physicians (who have relationships or preconceptions that you alone cannot overcome). However, getting physician support is crucial for the success of the navigation program and to measure patient satisfaction with and without a navigation program.

– Do not track the number of specific procedures performed regardless of stage of cancer or patient preference (which might prove to be stronger factors than navigation alone).

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Table

Patient Care Outcome Metrics to Evaluate the Patient Navigator Program

Addressing the Factor

Measuring Reliable Factors

How to Collect the Data

Provide assistance with transportation

• The number of “no shows” at treatment or follow-up appointments • Lost revenue from missed appointments or out-migration

• EMR: automated reports of cancellations • No EMR: receptionist records on written log daily • Captured charges for each patient provided with transportation to treatment

Financial counselor assistance with obtaining insurance coverage

• The number of patients counseled relative to the amount of reimbursed care given • Reviewing federally funded programs for enrollment (eg, CEED grant for screening affords access to Medicare when diagnosed)

• Captured charges (rates or per patient)

Successful management of treatment toxicity

• Emergency room visits within 30 days of discharge for target ICD-9 codes • Readmission within 30 days of discharge for same admitting diagnosis

• Billing data

Clinical outcomes of cancer care

• Local tumor control • Survival rates • Functional status • Toxicity rates

• Tumor registrar or chart review • Tumor registrar • Psychosocial distress tool • Chart review or ICD-9 query

Improved patient compliance through education and communication

• Admissions by common toxicity (eg, constipation, nausea and vomiting, diarrhea, pain)

• Admissions by ICD-9 for specific problem

Improved patient comprehension and comfort with care plan

• Precounseling and postcounseling • Manually or through SurveyMonkey comprehension tests or other Web-based tool • Addition of navigation protocols for specific domains of care, ie, transitioning from surgeon to oncologist6

Assurance of appropriate, timely surveillance care after treatment (to prevent overutilization or underutilization)

• Surveillance laboratory test, procedure or physician visits for physical exam compared with national guidelines

• CPT codes

Improved enrollment in clinical trials

• Number enrolled per total number seen (best to measure for a specific patient population)

• Clinical trial data management system or written records

Improve referrals for genetic counseling and cancer risk assessment

• Number of referrals on site • Number of referrals to another facility or community-based organization

• EMR • Referral database

Overcoming Barriers

Appropriateness of Care

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Table

Patient Care Outcome Metrics to Evaluate the Patient Navigator Program (Continued...)

Patient Satisfaction Improve access to care; decrease patient wait times

• Median and range of wait times from • EMR: date from pathology diagnosis cancer diagnosis to subspecialist physician to patient appointment • Start of definitive treatment (surgery, • No EMR: manual collection chemotherapy, hormonal manipulation, • Tumor registrar or radiation)

Improve patient satisfaction with care

• Validated satisfaction tool • Use specific tool you design for your care process

Improve patient access to • Referrals to health professionals such as services that enhance comfort social workers, physicians, by gender, or other patient requests, nutrition, pain management, cancer rehabilitation

• Make sure oncology specialty services are monitored separately rather than grouped with ambulatory services or other general group • Involve many people in design; acknowledge as a not-yet-validated tool • Monitor gifts from grateful patients/families • Billing data or manual tracking

Employee Satisfaction Improve employee satisfaction to decrease turnover, providing more consistent care for patients and preventing cost of employee replacement

• Physician satisfaction • Nurse (non-navigator) satisfaction • Physician productivity

• Customized tool asking how navigator role makes physicians or nurses more efficient • RVU prenavigation and postnavigation

Prevention of patient out-migration

• Care delivered within or outside system as measured by the proportion of patients leaving the system • Track only patients leaving the system and estimate lost revenue according to evidence-based guidelines

• Tumor registrar data, zip code data, or manual tracking • CPT codes with physician input by cancer primary site

Increase “downstream revenue” for patients with cancer treated at your institution

• Laboratory or radiology tests, support • Billing data (technical and services, hospice care, cancer rehabilitation, professional) evidence-based cancer surveillance care procedures (colonoscopy, follow-up physical exams)

Ensure cancer-specific program growth

• Procedure-specific incremental revenue (prenavigation and postnavigation)

• Billing data (technical and professional)

Improve care provider productivity

• Volume of patients treated/undergoing procedures (prenavigation and postnavigation)

• Captured charges (most meaningful to hospital administration) • Physician- or physician groupspecific RVU

Increasing Revenue

Abbreviations: CEED, Center for the Elimination of Disparities; EMR, electronic medical record; RVU, relative value unit.

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How can maintaining the confidentiality of patient and provider feedback contribute to the success of the program?

• Maintaining confidentiality is especially important when using patient or staff satisfaction surveys but should also be considered during focus or support groups. Constructive criticism is needed but will be gained only when those asked feel safe in sharing their opinions.

Will this measure prove that the program improves treatment outcomes?

• Select measures that demonstrate improved outcomes through evidence-based care (better yet, can you provide the new benchmark or standard of care?). This information can be used both for marketing campaigns and in negotiating contracts for care.

• Be sure to keep the data you measure simple; the more complex the data, the greater the opportunity for confounding variables.

Measuring the use of 1 treatment for a specific stage of cancer is better than looking at general outcomes for all patients with that type of cancer.

After refining what you want to measure for each specific question, thinking of your completed data as being able to tell a story that combines patients’ psychosocial and medical needs with the needs of the institution and/or care providers is helpful. Choose measures that are different from one another, and you will be sure to have a story to tell rather than a lecture on 1 aspect of care that might not interest everyone in your audience.

Last February, Mindstream Education held a meeting in Orlando during which the panelists and the audience came up with several measures and metrics to validate the benefits of patient navigation. Several general themes evolved with suggestions on how to monitor the collected data. The Table shows how the data should be collected, as a baseline before the navigation program exists or before any proposed enhancements, and then reported on a schedule that most relates to the urgency of the problem.

Being diagnosed with cancer can be devastating because patients worry about the unknown and what the future may hold for them. Cancer patients are compromised initially with the burden of a cancer diagnosis, and their coordination of care is yet another unnecessary stressor. Family caregivers for cancer patients experience high

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levels of stress and burden and diminished quality of life. Ongoing research in the search for a cure has resulted in increased treatment options and multiple modalities; consequently, the coordination of treatments and services has become extensive and complex for patients and their families.

In addition, exploring the best treatment options, such as clinical trials, procedures, and new drugs, without guidance can become cumbersome and overwhelming. Inadvertently, this causes delays in access to care, diagnosis, education, and treatment. How can a nurse navigator help? He or she can help by moving the patient smoothly through the healthcare system during the continuum of care.

As patient navigation services evolve and expand, nurses and social workers in oncology have roles in educating patients, survivors, families, healthcare teams and systems, and the public about patient navigation. Challenges revolve around measuring and ensuring desired and optimal outcomes for patients, families, survivors, and individuals in patient navigator roles and processes to address sustainability of navigation programs and services.7 g Disclosures: Ana Rosa Espinosa, DNP, MBA, RN, OCN, has no conflict of interest or financial interest to disclose. Molly Gabel, MD, has no conflict of interest or financial interest to disclose. Pamela Vlahakis, RN, MSN, CBCN, has no conflict of interest or financial interest to disclose.

REFERENCES 1. Paskett EH, Harrop JP, Wells KJ. Patient navigation: an update on the state of the science. CA Cancer J Clin. 2011;41:237-249.

2. Oncology Roundtable. Maximizing the value of patient navigation. The Advisory Board Company Web site. http://www.adviso ry.com/Research/Oncology-Roundtable/Studies/2011/Maximizing -the-Value-of-Patient-Navigation. Accessed September 25, 2012.

3. Whitley E, Valverde P, Wells K, et al. Establishing common cost measures to evaluate the economic value of patient navigation programs. Cancer. 2011;117(15 suppl):3618-3625.

4. American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care. Chicago, IL: American College of Surgeons; 2011.

5. Delivering on the promise of patient-centered care: designing services to support the whole patient. The Advisory Board Company Web site. http://www.advisory.com/Research/OncologyRoundtable/Studies/2011/Delivering-on-the-Promise-of-PatientCentered-Care. Accessed October 6, 2012.

6. Pedersen A, Hack TF. Pilots of oncology health care: a concept analysis of the patient navigator role. Oncol Nurs Forum.

2010;37(1):55-60.

7. Wells KJ, Battaglia TA, Dudley DJ, et al. Patient navigation: state of the art or is it science? Cancer. 2008;113(8):1999-2010.

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CALL FOR PAPERS The Journal of Oncology Navigation & Survivorship® (JONS), launched in 2010, is the nation’s first peerreviewed clinical journal for Oncology Nurse Navigators. As this critical area of specialty and expertise grows, research and sharing of best practices are integral to both improving the clinical care of cancer patients as well as expanding the existing literature and knowledge base. Our goal at JONS is to help facilitate that growth.

Readers are invited to submit articles that fit into the following topics: • Patient Education • Navigation Processes and Outcomes Measures • Continuity of Care • Working with a Multidisciplinary Oncology • Screening Programs Team • Community Outreach • Transitional Processes into Survivorship Care • Psychosocial Issues • Long-Term Follow-Up • Emotional Support • Patient Surveillance • Facilitation of Treatment Decision Making • Patient Adherence • Tumor Board Processes • Any other topic relevant and of importance • Caring for the Underserved to the specialty

Papers can be in the following form: • Original Research • Review Article (a synopsis/review of current literature in a specific area of research) • Case Study • “How To” article designed to transfer successes to fellow practitioners

Each manuscript is subject to an internal review to see that it fits the scope of and mission of our journal.

Papers that pass the initial review could be subject to a blinded peer review; final acceptance is based on that review.

If you are interested in submitting a paper or have any questions, please feel free to contact our editorial department at editorial@greenhillhc.com or jim@greenhillhc.com.

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Helping Your Patients Manage Chemotherapy-Induced Nausea and Vomiting

By Rosalie Canosa, LCSW-R Program Division Director, CancerCare

Sharon Gentry, RN, MSN, AOCN, CBCN Breast Nurse Navigator, Derrick L Davis Forsyth Regional Cancer Center, Winston-Salem, North Carolina

INTRODUCTION As healthcare professionals who work with people living with cancer, we often see patients when they are most vulnerable. For many patients, their moments of greatest vulnerability are at the time of diagnosis and while discussing treatment. During such moments, patients typically feel overwhelmed and inundated with a large amount of information to process and assimilate, while at the same time dealing with the emotional impact of a cancer diagnosis. Much of that information consists of basics on their type of cancer and the recommended course of therapy, including instructions on adhering to the therapeutic regimen. Not surprisingly, information and instructions from doctors and nurses may not be fully integrated, or may easily get “scrambled,” during such a tender time. Patients may therefore lack a full understanding of the importance of following those instructions, or may even forget them. While forgetting or not fully understanding disease-related information may have tremendous ramifications for many aspects of cancer care, it can be particularly impactful when dealing with the nausea and vomiting that is often caused by chemotherapy.

Rosalie Canosa, LCSW-R

Sharon Gentry, RN, MSN, AOCN, CBCN

22

CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING: THE SCOPE OF THE PROBLEM The benefits of cytotoxic chemotherapy are undisputed. It is a type of therapy that has extended the lives of untold millions of cancer patients.

Yet chemotherapy is often associated with unpleasant side effects that negatively affect patients’ quality of life. One of the more debilitating side effects is chemotherapy-induced nausea and vomiting (CINV), a term that describes the symptoms of nausea and vomiting that occur in reaction to chemotherapeutic agents.1 For cancer patients receiving chemotherapy or radiation therapy, CINV can compromise or negate the benefits of treatment by making it very difficult

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for the patient to adhere to the therapeutic regimen, or by triggering an interruption or delay of treatment.

While all patients undergoing chemotherapy are at risk of CINV, there are numerous factors that can heighten a patient’s risk of this dreaded complication. Such risk factors include2,3: • Age less than 50 years • Being female • Low alcohol intake (one or fewer drinks per day) • History of motion sickness, or of morning sickness with pregnancy • Fear of nausea from chemotherapy or a history of CINV • Anxiety or nausea associated with past stress • Current use of antidepressants or antianxiety medication There are also numerous treatment-related factors that can affect the incidence and severity of CINV. These include the dosage, schedule, and route of administration of the chemotherapy regimen; the level of emetogenicity (likelihood of causing vomiting) of the regimen; the use of multiple agents in the regimen; and multiple cycles of chemotherapy.2,4 Chemotherapeutic agents can be categorized according to emetogenicity. Highly emetogenic chemotherapy (HEC) denotes a regimen that induces emesis (vomiting) in more than 90% of patients in the absence of effective prophylactic antiemetic therapy,4 although only about 30% of these patients will vomit if they receive antiemetic prophylaxis before administration of HEC.3,5,6 A moderately emetogenic chemotherapy (MEC) regimen is one that carries a 30% to 90% risk of emesis.4 Regimens carrying a low risk of emesis are those that induce emesis in only 10% to 30% of patients, and treatments with minimal emetogenic risk cause emesis in less than 10% of patients.4 While CINV is quite common, its incidence can vary greatly and is difficult to determine. In a

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1996 clinical trial, CINV was reported in 47 of 48 patients (98%) receiving HEC without antiemetic therapy.7 In a 2004 trial in which 298 patients were treated with antiemetics while receiving MEC or HEC, one-third of the participants experienced acute nausea (ie, that which occurs within a few minutes to several hours after a chemotherapy dose), and the incidence of delayed nausea (ie, more than 24 hours after chemotherapy administration) was 60%.8 In a 2005 study of 857 women with breast cancer who received antiemetic prophylaxis while on MEC, half of the patients experienced CINV.9 Although the incidence of CINV has declined over the past decade, CINV remains a threat to patients with cancer.

CINV can have a profound impact on patients’ quality of life, potentially leading to metabolic imbalances, a decline in patients’ self-care and functional ability, worsening of patients’ performance status and mental status, nutrient depletion, anorexia, surgical wound dehiscence (bursting open or splitting), esophageal tears, and patients’ refusal, delaying, or prevention of additional therapy.10-13 CINV can also impose a significant socioeconomic burden by reducing employee productivity and boosting overall healthcare costs due to prolonged hospitalization and increased nursing expenses.14 A recent retrospective study calculated the mean cost of a CINVrelated hospital visit at $5299, with a mean perpatient cost of $731.15

experience may drive the selection of antiemesis therapy.

Serotonin (5-HT3) antagonists, a class of agents that includes dolasetron mesylate, granisetron, ondansetron, and palonosetron, are commonly used for the prevention and treatment of CINV. The oral and IV forms of these agents have been shown to have equivalent efficacy when administered at the appropriate doses,16,17 and granisetron is also available as a transdermal patch with demonstrated effectiveness for up to 5 days from first application. Another common preventive regimen is a “cocktail” containing the neurokinin-1 (NK-1) receptor antagonist aprepitant (or its IV version fosaprepitant), the corticosteroid dexamethasone, and a benzodiazepine agent such as olanzapine.4 Other types of agents,

THE VALUE OF ANTIEMESIS In our experience, CINV is easier to prevent than to treat. Many patients experience cancer as a chronic disease, and can benefit from the use of antiemetic medications during all phases of treatment. A variety of antiemetic agents are available, including those that can be administered by the oral, rectal, intravenous (IV), intramuscular, or transdermal route. IV agents may be appropriate for patients who are unable to swallow or digest tablets due to emesis, while others may benefit from having antiemetic medication delivered via a transdermal patch, which may help reduce the pill burden and simplify treatment for these patients. The National Comprehensive Cancer Network, in its latest antiemesis treatment guidelines,4 cautions that while some studies suggest that certain agents are equally effective on a population basis, individual patients may respond differently, and a patient’s individual

CHALLENGES IN ADHERING TO ANTIEMETIC MEDICATION REGIMENS Once a patient has started chemotherapy, anxiety and emotional stress may complicate any efforts to adhere to antiemesis therapy. This is especially true of patients having their first experience with chemotherapy, although it may still be a lingering issue through subsequent rounds.

All too often, when a patient is taught what to expect from chemotherapy, she nods and appears to understand the educational information and is sent home after round one. Three days later she feels sick and anxious. She may be experiencing a “drop-off” effect from the antiemesis regimen, or may not have taken the drugs as instructed. Even if she followed instructions, the drugs may not have worked as expected. “I don’t know what to do,” she says, adding that she feels so bad that the emergency room (ER) seems a reasonable option.

Two key nursing actions can help the patient

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Many patients experience cancer as a chronic disease, and can benefit from the use of antiemetic medications during all phases of treatment. such as phenothiazines, benzamides, antihistamines, butyrophenones, and cannabinoids, have also been used for antiemesis, although these have largely been replaced by the 5-HT3 antagonists.4

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through this vulnerable time. The first action is the “teach-back” method (also known as the “show-me” method or “closing the loop”), which must be undertaken before the patient leaves her first chemotherapy treatment session.18 Once the patient has been briefed on strategies to manage CINV, the “teach-back” method largely consists of asking the patient questions such as, “Tell me what you are going to do if you feel nauseous or have uncontrolled vomiting.” The patient’s answers may reveal that she did not fully understand the information you have provided and that more information is required. In such situations, chances are that the patient’s anxiety and insecu-

The challenges of managing CINV make it crucial...to encourage patients to communicate proactively with the health professionals who are coordinating their care. rity made her afraid to speak up during the briefing, or that she does not feel comfortable enough to ask questions about the antiemesis medication and its accompanying instructions. Whenever possible, it is important that the briefing include family members or whoever will be with the patient after treatment.

The second key action is to have a nurse navigator or clinical nurse call the patient at home after treatment. A review of the educational content, as well as an assessment of the efficacy of the antiemesis medications, can confer a measure of control to the patient at this critical time.

Documentation of “real-time” symptoms can lead to needed medication changes prior to the next cycle of treatment. In a 2010 article, Sprandio documented how a community oncology practice achieved a drop in ER visits as well as a decrease in unscheduled office visits when this quality check was implemented.19 The resulting cost savings from avoiding CINV-related hospital visits can thus be an important metric for nurse navigators to support their role.

Sometimes, financial difficulties can interfere with patients’ efforts to adhere to antiemetic therapy. For some patients, the cost of treatment is simply too high. Others may struggle to pay the

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co-pay, even if their insurance covers the rest of the cost. As a result, patients may skip or delay an antiemesis dose, an omission that can have a ruinous effect on their quality of life, not to mention their chemotherapy experience as a whole.

Some patients may have limited access to antiemesis treatment. A lack of reliable transportation may make it difficult, if not impossible, to get to the doctor’s office, clinic, or pharmacy.

Needless to say, a patient will have trouble adhering to a medication regimen if he lacks the means to obtain it. The role of the social worker or nurse navigator is critical in identifying such patients so financial issues can be addressed before they become a concern.

Oftentimes, adherence to antiemesis therapy is compromised by patients’ misperceptions of treatment. Fear of addiction (the risk of which is minimal with antiemesis medications) is a powerful force in our society, and some patients may opt to forgo antiemesis medication rather than endure the perceived stigma of being “on drugs.”

ENHANCING COMMUNICATION The challenges of managing CINV make it crucial for the oncology nurse, nurse navigator, and oncology social worker to encourage patients to communicate proactively with the health professionals who are coordinating their care. We need to tell patients not to be afraid to speak up if the antiemesis medication is not working, or if they do not fully understand the instructions for taking it. We need to make it clear that it’s OK to ask questions, and that a patient should not wait until the next appointment or next round of chemotherapy to raise her concerns.

In our experience, treatment-related information needs to be reinforced repeatedly. Not only is it important to ask patients if they truly understand what is expected of them, but it is also important to follow up and ask if they have been taking the medication as directed. Before they leave the clinic, it is helpful to have patients repeat the instructions back to you to make sure they understand them.

The importance of adhering to antiemesis medication cannot be overemphasized. We need to help patients overcome whatever fears or beliefs may be preventing them from adhering to antiemetic therapy. None of these fears or beliefs is a reason for any cancer patient to have to endure CINV, or to refuse or delay antiemesis therapy.

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Above all, patients need to feel empowered and equipped with the information they need to help them manage their disease. Organizations such as CancerCare offer a variety of educational resources specifically focusing on CINV (see Box). It is our obligation to share that information; we cannot assume that people will get it from some other source. At the same time, we need to work to ensure patients have the financial, logistical, and emotional support they need to access their medications and supportive care resources. In some cases, that support may consist of connecting patients with co-pay assistance programs, compassionate-use initiatives, or clinical trials. In other cases, we can help arrange transportation, or facilitate the involvement of family members, friends, or other caregivers to ease the burden on the cancer patient. If we are to give patients permission to be proactive in managing their disease, we must be proactive ourselves in helping them.

CONCLUSION From the time of diagnosis, the patient with cancer embarks upon a life-changing journey marked by multiple rounds of treatment and follow-up. The journey may include treatment response and cancer remission. On the other hand, the itinerary for the journey may change to account for disease progression and downstream treatment options. In most cases, the patient has not planned for this journey and may feel vulnerable, alone, and unprepared for the inevitable bumps in the road. If managed correctly and appropriately, CINV is a bump that can be avoided, or at least made less disruptive to the patient’s life. As oncology nurses, nurse navigators, and patient advocates, we are in an important position to help patients negotiate those challenges by providing and reinforcing treatment- and supportive care-related information, facilitating communication with doctors and other health professionals, and encouraging patients to be proactive in managing the various aspects of their care. In so doing, we can demonstrate to our patients that they are not alone. By serving as trusted guides, we may be able to make the cancer journey a bit less harrowing. g Disclosures: Rosalie Canosa, LCSW-R, has no conflict of interest or financial interest to disclose. Sharon Gentry, RN, MSN, AOCN,

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Helping patients manage CINV: CancerCare educational resources • Connect® Education workshops and podcasts: –Advances in Treating ChemotherapyRelated Nausea and Vomiting – Understanding and Managing Chemo therapy Side Effects • Publications – Coping With Nausea and Vomiting From Chemotherapy – Tips for Managing Nausea and Increasing Appetite During Cancer Treatment – Understanding and Managing Chemotherapy Side Effects – “Doctor, Can We Talk?” Tips for Communicating With Your Health Care Team • Online forums – Ask CancerCare: experts answer questions about coping with cancer

CBCN, has no conflict of interest or financial interest to disclose.

REFERENCES 1. Chemotherapy-induced nausea and vomiting. Mosby’s Medical Dictionary, 8th ed. Elsevier, Inc; 2009. TheFreeDictionary Web site. http://medical-dictionary.thefreedictionary.com/che motherapy-induced+nausea+and+vomiting. Accessed June 25, 2012.

2. Stricker CT, Eaby-Sandy B. Chemotherapy-induced nausea and vomiting. In: Brown CG, ed. A Guide to Oncology Symptom Management. Pittsburgh, PA: Oncology Nursing Society; 2010:91-122.

3. Hesketh PJ, Grunberg SM, Herrstedt J, et al. Combined data from two phase III trials of the NK1 antagonist aprepitant plus a 5HT3 antagonist and a corticosteroid for prevention of chemotherapy-induced nausea and vomiting: effect of gender on treatment response. Support Care Cancer. 2006;14(4):354-360.

4. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Antiemesis. Version 1.2012. http://www.nccn.org/professionals/physician_gls/pdf/antieme sis.pdf. Accessed November 7, 2011.

5. Hesketh PJ, Kris MG, Grunberg SM, et al. Proposal for classifying the acute emetogenicity of cancer chemotherapy. J Clin Oncol. 1997;15(1):103-109.

6. Roila F, Herrstedt J, Aapro M, et al. Guideline update for MASCC and ESMO in the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting: results of the Perugia consensus conference. Ann Oncol. 2010;21(suppl 5): v232-v2343.

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7. Kris MG, Cubeddu LX, Gralla RJ, et al. Are more antiemetic trials with a placebo necessary? Report of patient data from randomized trials of placebo antiemetics with cisplatin. Cancer.

1996;78(10):2193-2198.

8. Grunberg SM, Deuson RR, Mavros P, et al. Incidence of chemotherapy-induced nausea and emesis after modern antiemetics: perception versus reality. Cancer. 2004;100(10): 2261-2268.

9. Warr DG, Hesketh PJ, Gralla RJ, et al. Efficacy and tolerability of aprepitant for the prevention of chemotherapy-induced nausea and vomiting in patients with breast cancer after moderately emetogenic chemotherapy. J Clin Oncol. 2005;23(12): 2822-2830.

10. Laszlo J. Emesis as limiting toxicity in cancer chemotherapy. In: Laszlo J, ed. Antiemetics and Cancer Chemotherapy.

Baltimore, MD: Williams & Wilkins; 1983:1-5.

11. Ingle RJ, Burish TG, Wallston KA. Conditionability of cancer chemotherapy patients. Oncol Nurs Forum. 1984;11(4):97-102.

12. Mitchell EP. Gastrointestinal toxicity of chemotherapeutic agents. Semin Oncol. 1992;19(5):566-579.

13. Richardson JL, Marks G, Levine A. The influence of symptoms of disease and side effects of treatment on compliance with

cancer therapy. J Clin Oncol. 1988;6(11):1746-1752.

14. O’Brien BJ, Rusthoven J, Rocchi A, et al. Impact of chemotherapy-associated nausea and vomiting on patients’ functional status and on costs: survey of five Canadian centres. CMAJ. 1993;149(3):296-302.

15. Burke TA, Wisniewski T, Ernst FR. Resource utilization and costs associated with chemotherapy-induced nausea and vomiting (CINV) following highly or moderately emetogenic chemotherapy administered in the US outpatient hospital setting.

Support Care Cancer. 2011;19:131-140.

16. Kris MG, Gralla RJ, Clark RA, et al. Incidence, course, and severity of delayed nausea and vomiting following the administration of high-dose cisplatin. J Clin Oncol. 1985;3(10):13791384.

17. Kris MG, Hesketh PJ, Somerfield MR, et al. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. J Clin Oncol. 2006;24(18):2932-2947.

18. North Carolina Program on Health Literacy. Health Literacy Toolkit. Tool 5. http://www.nchealthliteracy.org/toolk it/tool5.pdf. Accessed September 7, 2012.

19. Sprandio JD. Oncology patient-centered medical home and accountable cancer care. Commun Oncol. 2010;7(12):565 -572.

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