TON May 2014 by The Oncology Nurse

May/June 2014

www.TheOncologyNurse.com

Vol 7, No 3

ONS Annual Congress

Cancer Center Profile

Cancer Hospital of New Jersey at Robert Wood Johnson University Hospital Prioritizing Patient Care for Improved Outcomes

Updates to ONS Chemotherapy and Biotherapy Guidelines Alice Goodman

he fourth edition of the Oncology Nursing Society (ONS) Chemotherapy and Biotherapy Guidelines and Recommendations for Practice weighs in at almost 500 pages and has some important updates since the last edition was published. At the ONS 39th Annual Congress, Martha Polovich, PhD, RN, AOCN, of Georgia State University in Jonesboro, and MiKaela Olsen, MS, RN, AOCNS, of Johns Hopkins Hospital in Baltimore, Maryland, reviewed important changes in the new guidelines.

The guidelines are available in print and online through ONS and in an electronic format for iPad users through iTunes. Also, ONS offers an online course about the guidelines at https://www.ons.org/chemoprovider-course/register-or-renew. ONS is currently fine-tuning the online course to make it more user-friendly. A major change to the guidelines is reorganization of the entire content into chapters based on similarities in content. “We put like content together,” said Polovich. “This is a big improvement.” Continued on page 6

Genetic Counseling

The Breast Care Connection team (left to right): Bobbie Brown, Receptionist; Lynn Lutwin, MSN, OCN, CBCN, Director; Vivian Owusu-Mensah, APN; and Bernilda Quinones, Breast Health Outreach Coordinator.

he Cancer Hospital of New Jersey at Robert Wood Johnson University Hospital (RWJUH) is the flagship hospital of the Rutgers Cancer Institute of New Jersey. It is the only comprehensive cancer center in New Jersey designated by the National Cancer Institute. The partnership between RWJUH and Rutgers Cancer Institute of New Jersey allows patients to receive care from research physicians in a state-of-the-art environment. Continued on page 8

Conference News

Highlights From the Oncology Nursing Society 39th Annual Congress Alice Goodman

he Oncology Nursing Society (ONS) held its 39th Annual Congress May 1-4, 2014, in Anaheim, California. Almost 3000 attendees from the United States and around the world had the opportunity to gain new knowledge, meet new people, and learn about the latest research and evidence-based practices.

Attendees had to choose from a wealth of offerings, including award-winning lectures, oral sessions, special interest group sessions, poster sessions, presentations at the ONS Learning Booth, and other events. Below are summaries of selected news highlights from the conference.

A Historical Overview of the Evolving Landscape of Genetic Counseling Cristi Radford, MS, CGC, Ambry Genetics Tuya Pal, MD, FABMG, Moffitt Cancer Center

enetic counseling as a profession began in 1969 with the establishment of the first master’s level graduate program in genetic counseling; as a process, however, it has evolved over a longer period of time. The term “genetic counseling” was coined in 1947 by Sheldon Reed, a geneticist, who used

the term to describe the process of providing genetic information and support to families. He believed that an “important requirement of the counselor was to have a deep respect for the sensitivities, attitudes and reactions of the patients.” 1 Physicians who worked in early medical Continued on page 18

inside Best Practices. . . . . . . . . . . . . . . Maximizing Safety of Chemotherapeutic Drugs During Pregnancy ONS Annual Congress IOM Report on Cancer Care Decoded . . . . . . . . . . . . . . . . . . . ONS Exercise Campaign Aims to Improve Outcomes. . . . . . . . . . . . . . Through the Eyes of an Advocate . . . . . . . . . . . . . . . The New Bold Frontier of the “War on Cancer”

6 7

Side Effects Management. . . Skin Toxicity With Targeted Agents Healthcare and Insurance . . . . . . . . . . . . . The ACA and Implications for Oncology Care Nutrition in Focus . . . . . . . . . Nutrition in the Multidisciplinary Team: Risk Identification and Intervention

13 15 16

Now enrolling: MURANO study Investigating the Selective BCL-2 Inhibitor GDC-0199/ABT-199 in Chronic Lymphocytic Leukemia GDC-0199/ABT-199 is an investigational agent that has not been approved by regulatory agencies.

A Phase III Study of GDC-0199/ABT-199 Plus Rituximab Compared With Bendamustine Plus Rituximab in Patients With Relapsed or Resistant Chronic Lymphocytic Leukemia (CLL)

GDC-0199/ABT-199 + rituximab

Phase III Relapsed or resistant CLL (N=370)

GDC-0199/ABT-199 continued for 2 years or until disease progression

Bendamustine + rituximab Randomize Primary Endpoint

Secondary Endpoints

• Investigator-assessed progression-free survival, defined as time from randomization until disease progression or death from any cause

• Overall response rate • Incidence of adverse events

Key Inclusion Criteria

Key Exclusion Criteria

• Adult patients ≥18 years of age • Diagnosis of CLL per diagnostic criteria and relapsed or refractory CLL per the iwCLL guidelines • Previously treated with 1-3 lines of therapy (eg, completed ≥2 treatment cycles per therapy), including ≥1 standard chemotherapy-containing regimen • Previously treated with bendamustine, only if duration of response was ≥24 months • ECOG performance status of 0-1 • Adequate bone marrow function • Adequate renal and hepatic function

• Transformation of CLL to aggressive non-Hodgkin lymphoma or CNS involvement by CLL • Undergone an allogenic stem-cell transplant • A history of significant renal, neurologic, psychiatric, endocrine, metabolic, immunologic, cardiovascular, or hepatic disease • Hepatitis B, hepatitis C, or known HIV-positive • Receiving warfarin treatment • Received an anti-CLL monoclonal antibody within 8 weeks prior to the first dose of study drug • Received any anticancer or investigational therapy within 14 days prior to the first dose of study drug or has not recovered from previous therapy • Received CYP3A4 inhibitors (such as fluconazole, ketoconazole and clarithromycin) or inducers (such as rifampin, carbamezapine, phenytoin, St John’s Wort) within 7 days prior to the first dose of GDC-0199/ABT-199 • Prior GDC-0199/ABT-199 treatment

To learn more about this study, please visit www.ClinicalTrials.gov (NCT02005471, GO28667) or call the Trial Information Support Line at 1-888-662-6728.

GDC-0199/ABT-199 is being codeveloped by AbbVie and Genentech, a member of the Roche Group.

Reference: ClinicalTrials.gov, as of 5/2014. A2396579

Editorial Board EDITOR-IN-CHIEF

Beth Faiman,

PhD(c), MSN, APRNBC, AOCN Cleveland Clinic Taussig Cancer Institute Cleveland, OH

Catherine Bishop, DNP, NP, AOCNP

Shannon Hazen,

Melinda Oberleitner, RN,

Karla Wilson,

College of Nursing and Allied Health Professions University of Louisiana Lafayette, LA

City of Hope National Medical Center Duarte, CA

Patricia Irouer Hughes, RN, MSN,

Jayshree Shah, RN, APN-C, AOCNP, MSN, BSN, BS

Pharmacy John F. Aforismo, RJ Health Systems International, LLC Wethersfield, CT

RN, BSN, OCN Novant Health Presbyterian Cancer Center Charlotte, NC

DNS, APRN, CNS

Johns Hopkins Kimmel Cancer Center/Sibley Infusion Washington, DC

BSN, OCN

Piedmont Healthcare Rex, GA

John Theurer Cancer Center Hackensack University Medical Center Hackensack, NJ

Deena Damsky Dell, MSN, RN-BC,

Taline Khoukaz,

Gary Shelton,

AOCN, LNC

Fox Chase Cancer Center Philadelphia, PA

Wendy DiSalvo,

DNP, APRN, AOCN Genentech New London, NH

Denice Economou,

RN, MN, CNS, AOCN City of Hope National Medical Center Duarte, CA

Constance Engelking, RN,

MS, CNS, OCN

The CHE Consulting Group, Inc. Mt. Kisco, NY

Amy Ford, RN,

BSN, OCN Biodesix, Inc. Dallas, TX

NP, MSN, ACNP-C University of Southern California Norris Cancer Center & Hospital Los Angeles, CA

Sandra E. Kurtin, RN, MS, AOCN, ANP-C

MSN, NP, ANP-BC, AOCNP NYU Clinical Cancer Center New York, NY

Lori Stover, RN, BSN

Arizona Cancer Center Tucson, AZ

Western Pennsylvania Cancer Institute Pittsburgh, PA

Ann McNeill,

Joseph D. Tariman,

MSN, RN, NP-C, OCN John Theurer Cancer Center Hackensack University Medical Center Hackensack, NJ

Kena C. Miller, RN, MSN, FNP

Roswell Park Cancer Institute Buffalo, NY

Patricia Molinelli, MS, RN, APN-C, AOCNS

Somerset Medical Center Somerville, NJ

PhD, ANP-BC DePaul University Chicago, IL

RN, MSN, FNP-C, CPON

BSc Pharm, RPh, FASCP

Nutrition Karen Connelly, RD, CSO

Somerset Medical Center Somerville, NJ

Patient Advocacy Peg Ford

Ovarian Cancer Alliance San Diego, CA

Social Work Carolyn Messner, DSW, MSW, LCSW-R, BCD CancerCare New York, NY

Jacqueline Marie Toia, RN, MS, DNP Northwestern University Myeloma Program Chicago, IL

Pamela Hallquist Viale, RN, MS,

CS, ANP, AOCN Saratoga, CA

Genetic Counseling Cristi Radford, MS, CGC Ambry Genetics Sarasota, FL

Managed Care and Pharmaceutical Management Burt Zweigenhaft, BS

Onco360/OncoMed New York, NY

Sharon S. Gentry, RN, MSN, AOCN, CBCN

Ellen A. Neylon, MSN, FNP-BC, CCRP, OCN

Novant Health Derrick L. Davis Cancer Center Winston-Salem, NC

Columbia University Medical Center Center for Lymphoid Malignancies New York, NY

Cassandra J. Hammond, RN,

Dolores “Jeff” Nordquist, RN, MS,

MSN, CRNP

Avid Education Partners, LLC Sharpsburg, MD

www.TheOncologyNurse.com

CS, FNP

Mayo Clinic Rochester, MN

Connie Visovsky,

PhD, RN, ACNP-BC University of South Florida College of Nursing Tampa, FL

Rita Wickham,

PhD, RN, AOCN Northern Michigan University Independent Oncology & Palliative Care Consultant Marquette, MI

Isabell Castellano, RN

Bristol-Myers Squibb Children’s Hospital Robert Wood Johnson University Hospital New Brunswick, NJ

Jeanne Westphal, RN

Meeker County Memorial Hospital Litchfield, MN

May/June 2014 I VOL 7, NO 3

From The Editor PUBLISHING STAFF Senior Vice President, Sales & Marketing Philip Pawelko ppawelko@the-lynx-group.com Group Director, Sales & Marketing

John W. Hennessy jhennessy2@the-lynx-group.com Publisher Russell Hennessy rhennessy@the-lynx-group.com Editorial Director Kristin Siyahian ksiyahian@the-lynx-group.com Managing Editor Kristen Olafson kolafson@the-lynx-group.com Copy Editors Mollie Friedman Peggy Roeske Editorial Assistant Jennifer Brandt Production Manager Cara Nicolini

t’s a busy time in the world of oncology as this issue of The Oncology Nurse-APN/ PA (TON) comes together. The Oncology Nursing Society (ONS) held its 39th Annual Congress in early May while the 2014 Annual Meeting of the American Society of Clinical Oncology (ASCO) took place May 30 to June 3. TON was at both events. This issue presents some of our coverage of the news Beth Faiman, PhD(c), from the ONS. The next several MSN, APRN-BC, AOCN Editor-in-Chief issues of TON will cover more news from ONS as well as bring you some of the news from ASCO. Be sure to read the article about the updated edition of the ONS Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Martha Polovich, PhD, RN, AOCN, and MiKaela Olsen, MS, RN, AOCNS, reviewed important changes in the new guidelines and

we summarize some of the key points of their presentation. Martha Polovich noted, “These 500-page guidelines are not written by one individual. Many contributors wrote specific chapters. Then these evidence-based guidelines go to field reviewers. This is a project that comes out every 5 or 6 years.” Needless to say, these guidelines address issues that we all will incorporate into our daily practice. We talked to several nurse presenters at ONS and have news briefs that address issues ranging from hypnosis use by nurses to reduce the frequency of hot flashes in cancer survivors to how specific changes in nursing practice reduced the rates of central line–associated bloodstream infections. This year ONS will launch its “Get Up, Get Moving” campaign, with the aim of increasing physical activity in patients with cancer. The campaign hopes to encourage oncology nurses to become actively involved in recommending exercise to their patients. Please read the article about this ONS presentation and then go to www. TheOncologyNurse.com to participate in the poll and tell us how you discuss exercise with your patients. l

The Lynx Group

Reader Poll

President/CEO Brian Tyburski Chief Operating Officer Pam Rattananont Ferris Vice President of Finance Andrea Kelly Human Resources Jennine Leale Associate Director, Content Strategy & Development John Welz

Do you talk to your patients about the importance of exercise?

Director, Quality Control Barbara Marino Quality Control Assistant Theresa Salerno

o Yes

Director, Production & Manufacturing Alaina Pede Director, Creative & Design Robyn Jacobs

©iStockphoto.com/AlexRaths

Creative & Design Assistant Lora LaRocca

he Oncology Nursing Society (ONS) will be launching its “Get Up, Get Moving” campaign later this year. This program is aimed at encouraging nurses to become actively involved with recommending exercise to their patients. “If every one of us told each of our patients that if they exercised they could improve outcomes, that would make a tre-

Director, Digital Media Anthony Romano Web Content Managers David Maldonado Anthony Trevean Digital Programmer Michael Amundsen Meeting & Events Planner Linda Sangenito Senior Project Manager Jini Gopalaswamy Project Coordinators Jackie Luma Deanna Martinez IT Specialist Carlton Hurdle Executive Administrator Rachael Baranoski Administrative Coordinator Stephanie Ramadan Office Coordinator Robert Sorensen

Green Hill Healthcare Communications, LLC 1249 South River Road - Ste 202A Cranbury, NJ 08512 phone: 732-656-7935 • fax: 732-656-7938

May/june 2014 I VOL 7, NO 3

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mendous difference,” said Kristen Fessele, PhD, RN, AOCN, one of the presenters who discussed the program at the ONS 39th Annual Congress. When Fessele polled the ONS audience, about 20% said they routinely recommend exercise to their patients. Do you discuss exercise with your patients? Why or why not? If you do, how do you approach the topic?

Go to www.TheOncologyNurse.com to answer the question and add your comments.

The Oncology Nurse-APN/PA®, ISSN 1944-9798 (print); ISSN 1944-9801 (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 ©2014 by Green Hill Healthcare Communications, LLC. All rights reserved. The Oncology Nurse-APN/PA® 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 EDITORIAL DIRECTOR, The Oncology Nurse-APN/PA®, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. E-mail: editorial@greenhillhc.com. YEARLY SUBSCRIPTION RATES: United States and possessions: individuals, $105.00; institutions, $135.00; single issues, $17.00. 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 The Oncology Nurse-APN/PA® do not necessarily reflect those of the Editorial Board, the Editorial Director, or the Publisher. Publication of an advertisement or other product mentioned in The Oncology Nurse-APN/PA® 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.

www.TheOncologyNurse.com

Best Practices

Maximizing Safety of Chemotherapeutic Drugs During Pregnancy Caroline Helwick

ith little information in the literature, oncology professionals may feel insecure about

the use of chemotherapy in a pregnant patient. Attendees at the Hematology/ Oncology Pharmacy Association 10th

Annual Conference received some guidance from Erica Hochard, PharmD, hematology/oncology clinical pharmacist

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The Academy of Oncology Nurse & Patient Navigators (AONN+) invites you to share your story of how cancer has affected you or a loved one. These stories will serve as a forum to build awareness and be a source of inspiration and reassurance to others. Select stories will be featured on the AONN+ website and in future issues of the Journal of Oncology Navigation & Survivorship®.

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at the University of Kansas Hospital, Kansas City. Hochard sought to “clarify the conundrum” regarding the safety of chemotherapy during pregnancy, she said, by outlining what is known about risks—which drugs to avoid and which can be safely given. The information should help oncology professionals “make good clinical recommendations for these patients,” she explained. Cancer During Pregnancy Approximately 6000 pregnant women are diagnosed with cancer each year—an estimated 1 in 1000 pregnancies. As more women delay childbearing, this number is expected to increase. These cancers are most likely to be cervical, followed by breast, melanoma, Hodgkin lymphoma, and non-Hodgkin lymphoma. Since suboptimal doses of chemotherapy may predispose patients to recurrence, weight-based dosing is recommended, with doses adjusted for continued weight gain as pregnancy progresses, Hochard advised. Most chemotherapy agents are rated as Category D in terms of fetal risk, indicating there is positive evidence of human fetal risk based on adverse reaction data; nevertheless, the potential benefits may warrant the use of the drug during pregnancy. Almost all agents have been found to be teratogenic in animals, but in humans it has been difficult to interpret retrospective data since most drugs are used in combination, she pointed out. “In general, the teratogenicity of a drug depends on the timing of exposure, dose, and drug characteristics,” Hochard said. During the first 4 weeks, when the embryo is undifferentiated, there is an “all or none phenomenon,” wherein either the fetus aborts or the pregnancy continues. The first trimester, when organogenesis occurs, carries a risk of spontaneous abortion, fetal death, and congenital malformation as high as 20%. The main concern during the second and third trimesters is the risk that chemotherapy imposes on intrauterine growth restriction; however, the risk of fetal malformation diminishes to only 1.3%. “Malformations and toxicity to the fetus are really a reflection of gestational age,” Hochard noted. Treatment considerations should include maternal prognosis, trimester of pregnancy, feasibility of delaying chemotherapy until after the first trimester, timing of chemotherapy to avoid delivery during the maternal nadir, and chemoContinued on page 20

www.TheOncologyNurse.com

May/June 2014 I VOL 7, NO 3

ONS Annual Congress

Updates to ONS Chemotherapy…

MiKaela Olsen, MS, RN, AOCNS (left), and Martha Polovich, PhD, RN, AOCN, discuss the updates to the new edition of the ONS Chemotherapy and Biotherapy Guidelines and Recommendations for Practice.

There are now 11 chapters in the updated guidelines. Chapter 5 focuses on nursing considerations in cancer treatment and includes all of the safety information in one place; this chapter covers ethical and legal issues, American Society of Clinical Oncology and ONS chemotherapy administration safety standards, patient safety, and safe handling and disposal of hazardous drugs.

Chapter 10 focuses on posttreatment care and incorporates monitoring; this chapter covers survivorship, late effects of treatment, collaborative management, nursing assessment, screening recommendations, and patient education. New additions to the guidelines include information on chemotherapy sequencing as well as dosing in obese patients, Polovich continued. The addition of

Continued from cover

sequencing information is important, because the order of drug administration may affect the toxicity or clinical benefit of chemotherapy. A sequencing table is included. Chemotherapy dosing in obese patients is another topic that needs clarification. The updated guidelines state the following: • Use actual body weight to calculate doses. • Use full weight-based doses. • Adjust for comorbidities or toxicity. • Question dose “caps”—must have a rationale for that. “If you don’t use full weight-based doses you may be compromising survival. This is the first time this precaution appears in the guidelines,” Polovich told listeners. Olsen cited all the new drugs added to the guidelines: 10 new chemotherapy agents, 13 new small molecules, 6 new monoclonal antibodies, and 3 new other biologic therapies. New chemotherapy agents are bendamustine, cabazitaxel, clofarabine, decitabine, eribulin, nelarabine, omacetaxine, pralatrexate, romidepsin,

and vorinostat. The small molecules are axitinib, bosutinib, cabozantinib, carfilzomib, crizotinib, everolimus, pazopanib, regorafenib, ruxolitinib, vandetanib, vemurafenib, vismodegib, and zivaflibercept. New monoclonal antibodies are ado-trastuzumab, brentuximab, denosumab, ipilimumab, ofatumumab, and pertuzumab. The new “other” biologics are plerixafor, pomalidomide, and sipuleucel-T. Another change pertains to labeling. In the past, some red labels listed a route that should not be used. This was confusing, and some healthcare providers may mistakenly see only the route mentioned in the labeling, not the “DON’T” part. So now labels for drugs that should not be given intrathecally will be required to state “FOR INTRAVENOUS USE ONLY. FATAL IF GIVEN BY OTHER ROUTES.” The guidelines also state that vincristine and other vinca alkaloids should be administered intravenously using a minibag. Olsen said she was resistant to this

IOM Report on Cancer Care Decoded Alice Goodman

Mary McCabe, RN, MA

Betty Ferrell, RN, PhD, MA, FAAN

ancer care in the United States is reaching crisis proportions, with costs spiraling out of control and some patients getting suboptimal care. The Institute of Medicine (IOM), an independent nonprofit organization that provides unbiased reports to the public and policy makers, convened a committee of experts to address the crisis in cancer care and formulate goals for addressing the broken healthcare system. The full report and an important video are available on the IOM website: http://www.iom.edu/Reports/2013/ Delivering-High-Quality-Cancer-Care-Chartinga-New-Course-for-a-System-in-Crisis/Videos. aspx. Two Oncology Nursing Society (ONS) members— Betty Ferrell, RN, PhD, MA, FAAN, research scientist at the City of Hope National Medical Center in Duarte,

May/june 2014 I VOL 7, NO 3

California, and Mary McCabe, RN, MA, director of the Cancer Survivorship Center at Memorial Sloan Kettering Cancer Center, New York City—participated on the IOM expert committee. At the recent ONS 39th Annual Congress, they decoded the IOM report and discussed implications for oncology nurses at this critical juncture in history. “Our culture says the more we do, the better. We need to stop the fast-moving train we are on and consider what high-quality cancer care would look like. A major shake-up is necessary. We are at a critical crossroad. Our current system delivers suboptimal care at too great a cost,” Ferrell stated. “Cancer care is not as patient centered, accessible, coordinated, or as evidence based as it should be. It is easier said than done to achieve this,” Ferrell noted. Drivers of the current healthcare crisis include an aging population with several comorbidities, a workforce shortage of oncologists and nurses (about 50% of oncology nurses are reaching retirement age), reliance on family as providers of direct care, the rising and untenable costs of cancer care, and the limitations of current tools to assess quality of care. “The cost of cancer care is expected to increase by 39% in the year 2020. Unless we [as nurses] participate in those discussions, cuts in cost may occur in the wrong places. We need to think about how to bend the cost curve. What does quality mean? How does cost influence quality? How do we provide quality care at a cost we can afford? Even the co-pays for biologics and targeted therapies are overwhelming, and often these drugs improve survival by weeks or months. We need to think about whether we can afford these drugs,” Ferrell said. In addition, the cost of end-of-life care and overuse of testing also needs to be rethought. Many patients prefer to die at home and not undergo

expensive treatments at end of life. Palliative care is often a better option and should be initiated sooner in the course of illness, she said. Better tools are needed to evaluate current practices and identify those that work and those that are inappropriate, and then to disseminate results of those assessments. “We propose that patients be informed and that cancer care be focused on patients’ needs, values, and preferences. We also propose that there be an adequately staffed, trained, and coordinated workforce to provide team-based care for patients and incorporate their values and preferences,” McCabe stated. Other recommendations include evidence-based cancer care, and employing scientific research such as clinical trials and comparative effectiveness research to design better systems. The report also calls for “a learning healthcare information technology (IT) system for cancer” to improve the quality of care delivery, as well as translation of evidence into clinical practice, quality measurement, and performance improvement. Finally, the report calls for accessible and affordable cancer care, which is one of the greatest hurdles to implementing high-quality care. “We have a long way to go. We can work with individuals or groups to explain about health exchanges. We need to develop patient-centered high-quality cancer care and improve communication among ourselves and with our patients,” McCabe said. “We want to make this report an actionable tool and a living document.” l Reference

Ferrell B, McCabe M. Deciphering the IOM report “Delivering HighQuality Cancer Care: Charting a New Course for a System in Crisis”: the oncology nursing call to action. Presented at: Oncology Nursing Society 39th Annual Congress; May 1-4, 2014; Anaheim, CA.

www.TheOncologyNurse.com

ONS Annual Congress change at first, but not one single extravasation has occurred since they switched to minibags. “Vinca alkaloids and bortezomib can be fatal if administered in a route other than IV. Go back and look at your labels,” she told listeners. Another change is information on intrathecal (IT) medications. These should never be administered in the same room as intravenous (IV) chemotherapy, she said. IT drugs should be given on different days and in different settings than IV medications. Only healthcare providers with specialized education should prescribe, prepare, and administer IT chemotherapy. Orders for IT drugs should be written on a separate form from those for IV chemotherapy, and institutions

Only healthcare providers with specialized education should prescribe, prepare, and administer IT chemotherapy. should have a list of drugs that cannot be be given intrathecally. Furthermore, IT drugs should be prepared as close to the time of administration as possible. They should be packaged, transported, and stored in designated containers separately from IV or other drugs. They need to be clearly labeled “FOR INTRATHECAL USE.” “Conduct a timeout immediately before IT chemotherapy administration

and a 2-person check with a chemotherapy-competent nurse,” Olsen stated. A new and simplified rating system for emetogenicity of drugs is included in the guidelines as follows: high emetogenicity, 90%-100%; moderate emetogenicity, 30%-90%; low emetogenicity, 10%-30%; and minimal emetogenicity, <10%. Also, the guidelines include a new table on the emetogenicity of oral medications as well as treatment guidelines for each level of

emetogenicity. Fosaprepitant is the only new antiemetic agent included in the guidelines. “These 500-page guidelines are not written by one individual. Many contributors wrote specific chapters. Then these evidence-based guidelines go to field reviewers. This is a project that comes out every 5 or 6 years. We thank everyone involved,” Polovich said. Polovich, Olsen, and Kristine B. LeFebvre, MSN, RN, AOCN, served as editors of the fourth edition of the ONS Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. l Reference

Olsen M, Polovich M. 2014 chemotherapy and biotherapy guidelines: here’s what’s new. Presented at: Oncology Nursing Society 39th Annual Congress; May 1-4, 2014; Anaheim, CA.

ONS Exercise Campaign Aims to Improve Outcomes Alice Goodman

he Oncology Nursing Society (ONS) is gearing up to launch its “Get Up, Get Moving” campaign in the fourth quarter of 2014. This initiative is aimed at increasing physical activity in patients with cancer, with the goal of improving outcomes. At the ONS 39th Annual Congress, Katrina Fetter, RN, BSN, OCN, of Lancaster General Hospital, Pennsylvania, gave attendees an overview of the rationale for the campaign.1 “Physical activity provides a big bang for the buck. For many years we were taught to encourage cancer patients to rest, but the reality is that we should be letting them know that physical activity can help them,” Fetter said. Physical activity is included in the ONS Putting Evidence Into Practice (PEP) resource as an evidence-based recommendation to help alleviate fatigue, anxiety, depression, and lymphedema, and emerging evidence suggests that physical activity can also improve sleep/wake disturbances and cognition, Fetter said. The US Department of Health and Human Services (HHS) recommends that all Americans exercise a minimum of 2.5 hours per week, but even some activity is better than none, she said. The HHS-recommended exercises have been adapted for cancer patients.2 “The benefits of exercise far outweigh the risks. Patients don’t need a lot of testing or referrals prior to recommending walking, and strength and flexibility training. For patients with special considerations, such as decreased bone density, fracture, or range of motion problems, be sure to recommend physical activity that is appropriate to their situation,” Fetter continued. Few long-term studies have evaluated physical activity in cancer patients. Studies suggest that physical activity will decline after a diagnosis of breast cancer, and it may take patients a long time to restart exercising, she noted. Although physical exercise has many benefits for patients with cancer, it appears that few physicians recommend physical activity. A 2010 ONS survey that included more than 1000 cancer patients and 39 prac-

www.TheOncologyNurse.com

Katrina Fetter, RN, BSN, OCN

Kristen Fessele, PhD, RN, AOCN

tice sites found that only 9.79% of patients received a recommendation to exercise. “There is a lot of room for nurses to fill this gap and help our patients,” Fetter told the audience. Barriers to recommending exercise include the false belief that cancer patients need rest. In addition, some nurses may feel that a recommendation to exercise falls within the physicians’ scope of practice. The “Get Up, Get Moving” awareness campaign hopes to encourage nurses to become actively involved with recommending exercise to their patients. The program will include an online education course, video, teaching scripts, and resources that will be available through local ONS chapters. “If every one of us told each of our patients that if they exercised they could improve outcomes, that would make a tremendous difference,” said Kristen Fessele, PhD, RN, AOCN, a research associate at ONS. “Be their cheerleader on a regular basis—even if you work in an outpatient setting. Encourage them. Exercise should be part of your patient education and symptom management,” she stated. When Fessele polled the audience, only about 20% of nurses said they recommend exercise routinely. Very few nurses said that their patients did any kind of exercise, and those who did were exercisers before their diagnosis. Patients who exercised before and after

diagnosis felt better than those who didn’t exercise or those who started to exercise only after diagnosis, said members of the audience. An audience member (Ellen Woods, RN, BSN, OCN, an oncology educator at Kaweah Delta Cancer Care Program, Visalia, California) said that her facility offers a free gym membership as part of the cancer patient’s packet, and 90% of patients take advantage of this program. Fessele said that every institution should offer a free gym membership as part of their services for cancer patients, as well as a pedometer. “Even a little exercise is better than none. Patients will believe it is important if you ask them about it at every visit. Believe in the power of what you say. Nurses can make a big difference in symptom management,” Fessele continued. “Exercise is low tech and low cost. Most patients can walk and do simple exercise. Obviously use your clinical judgment about which patients are ready to exercise,” she said. It is advisable to wait 8 weeks after surgery. l References

1. Fetter K. Don’t just sit there: ONS says “get up, get moving” to improve patient outcomes. Presented at: Oncology Nursing Society 39th Annual Congress; May 1-4, 2014; Anaheim, CA. 2. Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409-1426.

May/June 2014 I VOL 7, NO 3

From The Cancer Center EditorProfile

Cancer Hospital of New Jersey… Continued from cover In addition to oncology-focused services such as diagnostic, laboratory, and pain-management services, the cancer hospital offers patients education and psychological and spiritual support. Supportive services include the care of an oncology social worker, an oncology nutritionist, and a chaplain, as well as support groups, inpatient hospice, and complementary therapies—including YEAR IVERSARY reiki, and massage. AAN NNNacupuncture, IVERSARY

that provides such services as pet therapy, music and art, support groups, and massage. I also see patients one-on-one who need navigation assistance before and after diagnosis. Both nurse navigators see inpatients

at the hospital after surgery to provide information on our services and teach them postsurgery exercises. You wear many hats! What is the approach to care at RWJUH? LL: We are pro patient and foster a cul-

ture of kindness for employee-to-employee and employee-to-patient interactions. We prioritize patient care above everything else, and this leads to improved outcomes. Our patients have a positive outlook and know they are not alone, because we are here for them. At our

YE AR

ANNIVERSARY ANNIVERSARY

FIFTH ANNUAL

Navigation and Survivorship Conference September 18-21, 2014 • Walt Disney World Dolphin Hotel • Orlando, FL AONN+ LEADERSHIP

PROGRAM DIRECTOR Lynn Lutwin, MSN, OCN, CBCN

The Oncology Nurse-APN/PA spoke with Lynn Lutwin, MSN, OCN, CBCN, director of the Breast Care Connection at RWJUH about her career. What are your responsibilities at RWJUH? Lynn Lutwin (LL): I have various roles here at the hospital. I am 1 of 2 nurse navigators for breast cancer patients and patients with other types of cancers. The second nurse navigator is an advanced practice nurse (APN), and she reports to me. I oversee the Susan G. Komen grant for our hospital, and, through this grant, the APN performs physical exams on patients who do not have a primary care physician and need a mammogram. I also oversee a breast health outreach service and direct the lung cancer screening program. In addition, I am involved in helping to run the Alternative Therapy Program

We are pro patient and foster a culture of kindness for employeeto-employee and employee-to-patient interactions.

TARGET AUDIENCE

This educational educational initiative initiative isis directed directed toward toward oncology oncology nurse nurse navigators, navigators, patient patient naviganavigaThis tors, case case managers, managers, care care managers, managers, administrators, administrators, and and social social workers workers whose whose focus focus isis tors, on cancer cancer care care and and survivorship. survivorship. on

STATEMENT OF NEED/PROGRAM OVERVIEW

Lillie D. D. Shockney, Shockney, RN, RN, BS, BS, MAS MAS Lillie

University Distinguished Distinguished Service Service University Associate Professor Professor of of Breast Breast Cancer Cancer Associate Departments of of Surgery Surgery and and Oncology Oncology Departments Administrative Director, Director, The The Johns Johns Hopkins Hopkins Administrative Breast Center Center Breast Administrative Director, Director, Johns Johns Hopkins Hopkins Administrative Cancer Survivorship Survivorship Programs Programs Cancer Associate Professor, Professor, JHU JHU School School of of Medicine Medicine Associate Departments of of Surgery, Surgery, Oncology Oncology & & Departments Gynecology and and Obstetrics Obstetrics Gynecology Associate Professor, Professor, JHU JHU School School of of Nursing Nursing Associate Baltimore, MD MD Baltimore,

AONN+’s Fifth Fifth Annual Annual Conference Conference will will continue continue to to advance advance the the navigation navigation profession profession AONN+’s by expanding expanding the the scope scope of of educational educational sessions, sessions, networking networking opportunities, opportunities, and and poster poster by presentations. In In addition, addition, this this year’s year’s conference conference will will address address the the evolving evolving challenges challenges presentations. of program program improvement, improvement, the the role role of of personalized personalized medicine, medicine, and and implementing implementing best best of practices in in navigation, navigation, survivorship, survivorship, and and psychosocial psychosocial care care for for cancer cancer patients. patients. practices

EDUCATIONAL OBJECTIVES

After completing completing this this activity, activity, the the participant participant should should be be better better able able to: to: After Describe the the evolution evolution of of the the role role of of navigation navigation in in healthcare healthcare •• Describe Interpret strategies strategies for for navigating navigating diverse diverse patient patient populations populations by by cancer cancer type type and and envienvi•• Interpret ronmental factors ronmental factors Deﬁne ne methods methods for for providing providing patient patient support support and and guidance guidance in in the the age age of of personalized personalized •• Deﬁ cancer care care cancer Explain how how to to evaluate evaluate best best practices practices regarding regarding survivorship survivorship and and psychosocial psychosocial care care •• Explain

NURSING CONTINUING EDUCATION

Global Education Education Group Group isis accredited accredited as as a a provider provider of of continuing continuing nursing nursing education education by by Global the American American Nurses Nurses Credentialing Credentialing Center’s Center’s COA. COA. the This educational educational activity activity for for 15.75 15.75 contact contact hours hours isis provided provided by by Global Global Education Education Group. Group. This Nurses should should claim claim only only the the credit credit commensurate commensurate with with the the extent extent of of their their participation participation Nurses in the the activity. activity. in

AMERICAN CASE MANAGEMENT ASSOCIATION

Application for for certiﬁ certiﬁcation cation of of ACMA ACMA hours hours has has been been applied applied for for and and isis pending pending Application decision. decision. Sharon Gentry, Gentry, RN, RN, MSN, MSN, AOCN, AOCN, CBCN CBCN Sharon Breast Health Health Navigator Navigator Breast Derrick L. L. Davis Davis Forsyth Forsyth Regional Regional Cancer Cancer Derrick Center Center Winston-Salem, NC NC Winston-Salem,

This activity activity isis co-provided co-provided by by Global Global This Education Group Group and and Education Center of of Excellence Excellence Media, Media, LLC. LLC. Center

NATIONAL ASSOCIATION OF SOCIAL WORKERS

This program program has has been been submitted submitted and and isis pending pending approval approval by by the the National National Association Association This of Social Social Workers Workers for for continuing continuing education education contact contact hours. hours. of

DISCLOSURE OF CONFLICTS OF INTEREST

Global Education Education Group Group (Global) (Global) requires requires instructors, instructors, planners, planners, managers, managers, and and other other ininGlobal dividuals and and their their spouse/life spouse/life partner partner who who are are in in a a position position to to control control the the content content of of this this dividuals activity to to disclose disclose any any real real or or apparent apparent confl conflict ict of of interest interest they they may may have have as as related related activity to the the content content of of this this activity. activity. All All identifi identified ed confl conflicts icts of of interest interest are are thoroughly thoroughly vetted vetted by by to Global for for fair fair balance, balance, scientifi scientific c objectivity objectivity of of studies studies mentioned mentioned in in the the materials materials or or used used Global as the the basis basis for for content, content, and and appropriateness appropriateness of of patient patient care care recommendations. recommendations. as

AMERICANS WITH DISABILITIES ACT

Event staff staff will will be be glad glad to to assist assist you you with with any any special special needs needs (ie, (ie, physical, physical, dietary, dietary, etc). etc). Event Please contact contact Patrice Patrice Melluso Melluso prior prior to to the the live live event event at at pmelluso@the-lynx-group.com pmelluso@the-lynx-group.com Please and 516-835-6529. 516-835-6529. and

May/june 2014 I VOL 7, NO 3

www.TheOncologyNurse.com

Cancer Center Profile institution, all employees try to help patients in every way that they can. What is your biggest challenge? LL: My major challenge is finding the time to help all the patients who need help. One can only do so much in a given day. We see more than 1000 patients each year. Eventually, we may probably hire another nurse navigator.

What are the benefits of your job? LL: There are 3 main benefits. One is being able to help patients and families face their diagnoses and solve problems. The second is educating people in the community about cancer through our outreach program. The third is the ability to provide screening for patients who otherwise would not be able to afford it. This may change through the Affordable

AGENDA

Thursday, September 18 12:30 pm - 1:30 pm 3:30 pm - 4:30 pm 5:30 pm - 8:00 pm

Start a Subcommittee Meeting (non–CE-certified activity) Start an AONN Chapter Meeting (non–CE-certified activity) Welcome Reception and Keynote Session (non–CE-certified activity)

4:45 pm - 5:45 pm

Friday, September 19 Navigators Exploring Xtra Tracks (N.E.X.T.) Day

Breakfast/Session 1 sponsored by Celgene Corporation (non–CE-certified activity) 8:15 am - 9:15 am Session 2 sponsored by Lilly Oncology (non–CE-certified activity) 9:30 am - 10:30 am Session 3 sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. (non–CE-certified activity) 10:45 am - 11:45 am Session 4 (non–CE-certified activity) 12:00 pm - 1:00 pm Lunch/Session 5 sponsored by Millennium: The Takeda Oncology Company (non–CE-certified activity) 1:15 pm - 2:15 pm Session 6 (non–CE-certified activity) 2:30 pm - 3:30 pm Session 7 (non–CE-certified activity) 3:45 pm - 4:45 pm Session 8 (non–CE-certified activity) 4:45 pm - 6:15 pm Poster Question and Answer Session in the Exhibit Hall (non–CE-certified activity) 6:30 pm - 9:30 pm Heroes of Hope AONN+ Family Event at Epcot Center Extra registration fee required for this event. (non–CE-certified activity) 7:00 am - 8:00 am

Saturday, September 20

Meet the Experts Breakfast in the Exhibit Hall (non–CE-certified activity) 8:00 am - 8:15 am Welcome, Introductions & Business Update (non-CE-certified activity) - Lillie D. Shockney, RN, BS, MAS; Sharon Gentry, RN, MSN, AOCN, CBCN 8:00 am - 9:00 am General Session 1: Finding Humor Where You Least Expect It: An Oncology Nurse Navigator’s Experiences with Breast Cancer Lillie D. Shockney, RN, BS, MAS 9:00 am - 10:00 am General Session 2: Sex, Chemo, and Rock & Roll - Penny Daugherty, RN, MS, OCN 10:00 am - 11:00 am General Session 3: Navigation and Survivorship Standards —Are You Ready for Your Commission on Cancer Accreditation? Virginia Vaitones, MSW, OSW-C 11:00 am - 12:00 pm General Session 4: Multiorgan Site Navigation - Libby F. Daniels, RN, OCN 12:00 pm - 1:15 pm Poster Award Winner Announcements, Presentations, and Luncheon in the Exhibit Hall (non–CE-certified activity) 1:15 pm - 2:15 pm General Session 5: Pediatric Oncology Navigation and Survivorship - Kathy Ruble, RN, CRNP, PhD 2:15 pm - 3:15 pm General Session 6: Medical Home and Quality Accreditations Update - Maureen Lowry, RN, BSN, OCN; John Sprandio, MD 3:15 pm - 5:30 pm Exhibit Hall Open 3:15 pm - 3:30 pm Break in the Exhibit Hall (non–CE-certified activity) 3:30 pm - 4:30 pm Breakout Session 1 (Choose one of the following sessions) • Basic Navigation (0-2 years) - Britta Newcomer, RN 7:00 am - 8:00 am

www.TheOncologyNurse.com

6:00 pm - 10:00 pm

Care Act. Right now we target high-risk patients for low-cost CT scans for lung cancer screening as well as for breast cancer screening. How did you decide to become an oncology nurse? LL: I have a varied history. I have 3 master’s degrees (communication, medical anthropology, and nursing administra-

• Intermediate Navigation (3-5 years) - Lucy Gansauer, RN, MSN, CPSO, OCN - Elaine Sein, RN, BSN, OCN, CBCN • Advanced Navigation (5+ years) - Sharon Gentry, RN, MSN, AOCN, CBCN • Administrators - Lisa Shalkowski, RN, BSN, MSHA Breakout Session 2 (Choose one of the following sessions) • Breast Cancer Navigation and Survivorship • Hematologic Malignancies Navigation and Survivorship - Peg Rummel, RN, MHA, OCN • Head, Neck, and Neurologic Cancers Navigation and Survivorship - Tamara Bowen, RN, BSN, MHA • Gynecologic Cancers Navigation and Survivorship - Carol Cherry, MSN, RN, AOCNS, APNG Heroes of Hope AONN+ 2nd Annual Gala Extra registration fee required for this event. (non–CE-certified activity) TM

The Robert Wood Johnson University Hospital.

tion) and am now working on an MBA. For 18 years, I was a cancer registrar, analyzing data from facilities, abstracting the data, and defining trends. Then I went to nursing school, partly because I wanted to experience direct patient contact and partly because the time was right and a local college was offering evening nursing classes. Because of my history, oncology was the natural path.

Sunday, September 21

Breakfast in the Exhibit Hall (non–CE-certified activity) 7:45 am - 8:00 am Welcome - Lillie D. Shockney, RN, BS, MAS; Sharon Gentry, RN, MSN, AOCN, CBCN 8:00 am - 8:45 am General Session 6: Sharing Best Practices - Mandi Pratt-Chapman, MA 8:45 am - 9:30 am General Session 7: Lay Navigation - Jean B. Sellers, RN, MSN 9:30 am - 10:45 am General Session 8: Utilizing EPIC to Successfully Navigate Patients - Lisa DelPizzo, RN, MSN, CCM, CBPN-IC; Danielle Guillama, RN, BSN, OCN 10:45 am - 12:00 pm Exhibit Hall Open 10:45 am - 11:00 am Break in the Exhibit Hall (non–CE-certified activity) 11:00 am - 12:15 pm Breakout Session 3 (Choose one of the following sessions) • Lung Cancer Navigation and Survivorship - Caryn M. Vadseth, RN, BSN, OCN • Prostate Cancer Navigation and Survivorship - Frank dela Rama, RN, MS, AOCNS • Gastrointestinal/Colorectal Cancer Navigation and Survivorship - Allyson Foor; Gail Sullivan, RN, BS • Melanoma Navigation and Survivorship - Krista M. Rubin, MS, RN, FNP-C 12:15 pm - 1:30 pm Lunch/General Session 9: Cancer Support Community/ UF Health Cancer Center Pilot Program - Linda House, RN, BSN, MSN; Diane Robinson, PhD 1:30 pm - 2:30 pm General Session 10: Sexuality and Intimacy - Michael L. Krychman, MD, FACOG 2:30 pm - 3:30 pm General Session 11: Doctor, Doctor Lend Me Your Ear - Marisa C. Weiss, MD 3:30 pm - 3:45 pm Closing Remarks - Lillie D. Shockney, RN, BS, MAS; Sharon Gentry, RN, MSN, AOCN, CBCN 7:00 am - 7:45 am

*Agenda subject to change.

Complete agenda and faculty information available on our website at AONNonline.org

Blackout Times

†

Thursday, September 18 8:00 am - 8:00 pm Friday, September 19 6:30 am - 8:00 pm

Saturday, September 20 6:30 am - 8:00 pm Sunday, September 21 6:30 am - 8:00 pm

Please note that organizations may not hold functions during the defined “blackout” times unless approved by AONN+. AONN+ will strictly enforce the blackout times. Failure to have approval to hold any event in these established time frames may result in a fine and exclusion from all AONN+ events.

†

AONN2014ConfAd Asize_60914

My major challenge is finding the time to help all the patients who need help. One can only do so much in a given day.

What advice would you give to someone entering the field? LL: Being an oncology nurse is the most rewarding career in the world. Seek out positions in oncology units or floors, and try to become a navigator. It may take time to find your way. Joining the Oncology Nursing Society (ONS) can provide helpful information, open up opportunities, and allow networking. The same is true of local/regional ONS groups. Once you find a position that suits, you can grow within that position. What would you be if you were not an oncology nurse? LL: I would stay within oncology. I loved being a cancer registrar, looking at data and abstracting it so I could make sense of it all. l

May/June 2014 I VOL 7, NO 3

Conference News: ONS Continued from cover

Hypnosis by Nurses Reduces Hot Flashes Hypnosis appears to be a feasible and effective intervention for reducing the frequency of hot flashes in cancer survivors, according to a poster presentation (poster 68) by Debra Barton, RN, PhD, AOCN, professor at the University of Michigan School of Nursing in Ann Arbor. In a study she presented, hypnosis alone was as effective as venlafaxine alone, but adding venlafaxine to hypnosis did not further improve hot flash control.

The good news is that nurses can easily learn the hypnosis technique and use it as a tool in their practice, Barton said. The hypnosis technique used in the study was developed by Gary Elkins, PhD, at Baylor University in Texas and was designed to achieve deep relaxation and provide “cooling” suggestions when patients are in a hypnotic state. Barton and 3 nurse colleagues were taught the technique over a 3-day period, and their competence at the technique was assessed at a follow-up visit. Barton noted that patients could even induce hypnosis on their own, but she did not advise that. The study evaluated whether hypnosis could reduce the occurrence of hot flashes in 71 postmenopausal women

with and without cancer (fewer than half with cancer) with a mean age of 55 years and at least 28 hot flashes per week. “Research has shown that there is no difference in how women respond to hot flash treatment, whether they are on tamoxifen, or have surgical menopause, chemotherapy-induced menopause, or natural menopause,” Barton noted. The women were randomized to ven-

nous estrogen can reduce the frequency of hot flashes, its use in cancer patients is controversial, especially in those with estrogen-sensitive tumors. In the study, trained nurses hypnotized the subjects for 4 weekly sessions. The primary end point was change from baseline in severity and frequency of hot flashes at week 8, as measured prospectively by a hot flash score recorded in a patient diary.

“Hypnosis reduces hot flashes more than other mind-body interventions....” Debra Barton, RN, PhD, AOCN

lafaxine 75 mg/day with or without hypnosis; venlafaxine and sham hypnosis; hypnosis plus placebo; or sham hypnosis plus placebo (control arm). Sham hypnosis involved listening to white noise. In an interview, Barton emphasized how debilitating hot flashes can be, negatively impacting quality of life and emotional well-being. Although exoge-

At the end of the study, the hot flash scores decreased by 25% in the sham hypnosis/placebo control group, 51% in the hypnosis/placebo group, 52% in the hypnosis/venlafaxine group, and 52% in the sham hypnosis/venlafaxine group. All active treatment arms were significantly better than the control (sham hypnosis/placebo) arm.

Barton noted that Elkins achieves a 70% reduction in hot flashes with hypnosis, and said that with more experience with the technique, she expected hypnosis to be more effective than the 52% rate achieved in the study. Interestingly, both venlafaxine alone and hypnosis alone achieved a similar reduction in hot flash severity and frequency, but the combination was not additive. Further, women randomized to venlafaxine/sham hypnosis reported significantly more side effects than controls (sham hypnosis/placebo group). Hypnosis was well received by the patients, with 70% of those who received it saying that it was worth the time and effort. Barton said, “Hypnosis reduces hot flashes more than other mind-body interventions, such as paced breathing, and nurses are able to deliver hypnosis effectively. Given the side effects associated with venlafaxine, future research should focus on even lower doses of pharmacologic agents in combination with mind-body interventions.” She also noted that she plans to study the effects of hypnosis in cancer-related fatigue and sexual health (self-image of cancer patients). l

The Role of the Oncology Nurse in Managing Patients on Radium-223 Radium-223 is a first-in-class, alpha particle–emitting radiopharmaceutical approved for the treatment of men with castration-resistant prostate cancer (CRPC), symptomatic bone metastases, and no known visceral metastatic disease.1 The drug is remarkably safe and was approved on the basis of the phase 3 ALSYMPCA trial (N=921), which showed a significant prolongation in overall survival (median 14.9 months vs 11.3 months with placebo; P <.001).2

“This is a newly approved drug, and nurses don’t have a lot of experience with it. They may be fearful of using it. It can be given pre- or post-chemotherapy to men with bone metastasis, with minimal myelosuppression,” said Tracy Curley, RN, of Memorial Sloan Kettering Cancer Center in New York City. She presented a poster (poster 77) on the nurse’s role in patient care and management of men taking radium-223. “Nurses are essential members of the multidisciplinary team involved in managing patient care and educating patients on novel therapies,” she said.

“Educating patients about the unique properties and therapeutic benefits of radium-223, along with radiation safety, myelosuppression, and interventions for adverse events, is an essential part of the nursing role.” Patients should be educated about several issues: • Radium-223 is the first alpha particle–emitting radiopharmaceutical that prolongs survival and improves quality of life in men with CRPC and symptomatic bone metastases. • Patients taking this drug should comply with blood cell count monitoring and appointments, and report any shortness of breath, fatigue, bleeding, or infection. • To avoid myelosuppression, radium-223 should be discontinued when chemotherapy, other systemic radioisotopes, or external radiation therapy is to be given as treatment. • Patients must stay well hydrated during treatment and report any signs of dehydration, hypovolemia, urinary retention, or renal failure or insufficiency.

• Pain flares can occur as part of therapy, but this does not mean that the cancer is progressing; use adequate pain medication if needed. • There are no restrictions regarding contact with other people after radium-223 treatment. Because radium-223 is excreted through urine, feces, and vomit, important precautions should be taken. Patients must be mindful about disposing of bodily waste in a toilet and flushing several times. Clothes soiled with bodily fluids should be washed promptly and separately. Caregivers should wear gloves and wash hands after contact with patient’s bodily fluids or soiled clothes. Sexually active patients should wear condoms and should continue to do so for at least 6 months after treatment due to concerns of effects on sperm. l References

1. Xofigo [package insert]. Wayne, NJ: Bayer HealthCare Pharmaceuticals, Inc; May 2013. 2. Parker C, Nilsson S, Heinrich D, et al; for the ALSYMPCA Investigators. Alpha emitter radium-223 and survival in metastatic prostate cancer. N Engl J Med. 2013;369(3):213-223.

have you ever wanted to write an article for TON ? We’re interested in articles about the everyday issues that affect nurses—everything from chemotherapy safe handling to supportive care for patients to challenging cases.

Contact editorial@greenhillhc.com for information. 10

May/june 2014 I VOL 7, NO 3

www.TheOncologyNurse.com

Conference News: ONS

Safety Huddle for Patient Care Safety “huddles” are being instituted at a number of oncology facilities and play a key role in improving quality of care. The idea is to have a brief meeting (“huddle”) led by the charge nurse before each shift; the huddle includes all staff on the floor involved in patient care for that shift. Typical issues that might be discussed include problems with specific patients, fall risks, actual and potential discharges and admissions, staff needing assistance now, next shift assignment changes, and equipment supplies and needs, explained Gerry Finkelston, MSN, RN, CCRN, OCN, of the Cancer Treatment Centers of America in Philadelphia, Pennsylvania. A huddle typically

The idea is to have a brief meeting led by the charge nurse before each shift.

takes about 10 minutes and occurs at 11:00 AM and 11:00 PM before each shift at her center. “The huddles are easy to do and take about 10 minutes. The hardest part is to gather everyone on the floor together,” Finkelston said. Finkelston presented a poster (poster 86) on “Huddle With a Twist,” the “twist” being a weekly newslet-

ter that she writes featuring important issues discussed by the huddles on each floor during the preceding week. The newsletter highlights practice changes, educational offerings, and nurses’ accomplishments; shares an alignment message; and focuses on standard of care. It is emailed to the entire staff. The huddles are designed to foster team building and collaboration,

improve patient safety and patient flow, and update staff about any important concerns. They were designed in response to the following statement summing up a report by the Joint Commission: “In the acute care setting, communication failures lead to increases in patient harm, length of stay, and resource use, as well as more intense caregiver dissatisfaction and more rapid turnover.” l Reference

Dingley C, Daugherty K, Derieg MK, et al. Improving patient safety through provider communication strategy enhancements. In: Henriksen K, Battles JB, Keyes MA, et al, eds. Performance and Tools. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Advances in Patient Safety: New Directions and Alternative Approaches; vol 3. AHRQ Publication No. 08-0034-3.

Preventing CINV With Sustained-Release Granisetron (APF530) APF530, a subcutaneous (SC) formulation of granisetron, was noninferior to palonosetron in preventing both acute chemotherapy-induced nausea/vomiting (CINV) following moderately and highly emetogenic chemotherapy and delayed CINV after moderately emetogenic chemotherapy in a phase 3 study reported by Carrie Smith, RN, and Nashat Gabrail, MD, of the Gabrail Cancer Center in Canton, Ohio, in a poster presentation (poster 34). These findings suggest that APF530 is an effective alternative to palonosetron in preventing CINV after emetogenic chemotherapy, especially in the outpatient setting, they explained. Administration of SC APF530 does not require special nursing skills, and this formulation of granisetron was effective in both chemotherapy-naive and chemotherapy-experienced patients, they said. “In our experience, APF530 was effective regardless of patient age, sex, tumor type, and prior chemotherapy, which are important considerations for nurses caring for patients with cancer,” the authors stated.

The multicenter, randomized, double-blind, double-dummy, parallel-group phase 3 trial included 653 patients slated for moderately emetogenic chemotherapy and 742 patients for highly emetogenic chemotherapy. Patients were randomized to receive SC APF530 250 or 500 mg (equivalent to granisetron 5 or 10 mg) or palonosetron 0.25 mg in cycle 1. In cycles 2-4, patients randomized to palonosetron in cycle 1 received SC APF530 250 or 500 mg; those who received APF530 in cycle 1 continued with the dose they received in cycle 1. Standard-dose intravenous dexamethasone was given to all patients prior to chemotherapy on day 1, and oral dexamethasone was given to patients receiving highly emetogenic chemotherapy on days 2, 3, and 4. Both the 250 mg and the 500 mg doses of APF530 were noninferior, but not superior, to palonosetron in preventing CINV in cycle 1; there were no significant differences in within-cycle complete response rates (no emetogenic episodes and no use of rescue medications) between both doses of APF530 during

acute and delayed phases in any of the cycles. Adverse events of APF530 were predominantly mild and considered unrelated to treatment. Injection site reactions occurred in all treatment groups, most commonly during cycle 1. Special instructions for nurses are that APF530 should be directly injected only into the abdomen; the agent is highly viscous, so the force required to inject it is directly proportional to the product’s temperature. APF530 should be refrigerated and removed 60 minutes before each use to bring it to room temperature, then the syringe should be warmed in the warming bag for at least 5 minutes to bring it to body temperature. APF530 can be put back in the refrigerator and rewarmed several times; it can also stay unrefrigerated for 7 days and be refrigerated up to 2 times. Once the product has been warmed to body temperature, and a local anesthetic applied to the abdomen, APF530 should be injected with a slow, firm, and steady push over 20 to 30 seconds. l

Changing Nursing Practice Reduces Infections Changes in nursing practice reduced the rates of central line–associated bloodstream infections (CLABSIs) by 41% hospital-wide and by 46% on the leukemia/lymphoma unit from the last quarter of 2012 to the first quarter of 2013 at Memorial Sloan Kettering Cancer Center in New York City. Further, patient outcomes improved and hospital costs decreased.

CLABSI is one of the most common hospital-acquired infections and increases the risk of mortality, length of hospital stay, and hospital costs. This recognition prompted an evidence-based review that led to a change in nursing practice and development of a CLABSI maintenance bundle. Hospital-wide nursing education on the maintenance bun-

www.TheOncologyNurse.com

An evidence-based review...led to a change in nursing practice and development of a CLABSI maintenance bundle. dle ensured standardized practice across the care continuum, explained Faye Inumerables, MSN, RN, and coauthors in a poster presentation (poster 88). All registered nurses attended an in-service 4-hour class that introduced the CLABSI maintenance bundle and a review of updates to the central venous access device (CVAD) policy. Nurses were taught the following:

• Use of Tegaderm chlorhexidine gluconate (CHG) dressing instead of the Biopatch and Tegaderm • Intravenous line change every 7 days instead of every 4 days • Importance of maintaining a closed system and use of disinfection caps over needleless connector sites • Daily use of 4% CHG for all patients with a CVAD

Following the 4-hour class, nurses were required to demonstrate central line dressing changes using Tegaderm CHG, and their competencies were reviewed using a checklist. The new equipment and policy were introduced at the beginning of 2013 throughout the hospital. CLABSI educators were present as a resource for nurses on each unit. The authors note that the reported CLABSI rates currently include cases meeting the criteria of the Centers for Disease Control and Prevention for mucosal barrier injury (MBI), but that MBI cases are not due to the central line. They hope to be able to exclude MBI cases in future analyses of the effect of the new practices related to CLABSI. l

May/June 2014 I VOL 7, NO 3

Through the Eyes of an Advocate

The New Bold Frontier of the “War on Cancer” Peg Ford

hen the fourth Illumina Discovery Symposium was presented in San Diego in conjunction with the 2014 meeting of the American Association for Cancer Research (AACR), I was fortunate to

be invited to attend. The symposium focused on the progress being made in monitoring cancer through next-generation sequencing technologies. From my perspective as a patient advocate, there were several issues, concerns,

and insights presented that caught my attention.

I thought the presentation by Shashikant Kulkarni, PhD, set the stage well. Dr Kulkarni is head of Clinical Genomics, Genomics and Pathology

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LynxCME is the new home of COEXM activities CONTINUING EDUCATION 6th Annual

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MAY 2013 • VOLUME 6 • NUMBER 2

CONSIDERATIONS in

Multiple Myeloma

™

www.lynxcme.com

ASK THE EXPERTS: Maintenance Settings PUBLISHING STAFF Group Director, Sales & Marketing John W. Hennessy john@greenhillhc.com Editorial Director Susan A. Berry susan@coexm.com Senior Copy Editor BJ Hansen Copy Editors Dana Delibovi Rosemary Hansen Grants/Project Associate Susan Yeager The Lynx Group President/CEO Brian Tyburski Chief Operating Officer Pam Rattanonont Ferris Vice President of Finance Andrea Kelly Director of Human Resources Blanche Marchitto Associate Editorial Director, Projects Division Terri Moore

LETTER

FROM THE

EDITOR-IN-CHIEF

Over the past decade, significant progress has been made in the management of multiple myeloma, including new standards of care and the development and approval of several novel, effective agents. Despite this progress, more work needs to be done and numerous questions remain regarding the application and interpretation of recent clinical advances. In this sixth annual “Considerations in Multiple Myeloma” newsletter series, we continue to explore unresolved issues related to the management of the disease and new directions in treatment. To ensure an interprofessional perspective, our faculty is comprised of physicians, nurses, and pharmacists from leading cancer institutions, who provide their insight, knowledge, and clinical experience related to the topic at hand. In this second issue, experts from Dana-Farber Cancer Institute answer questions related to the management of patients in the maintenance setting.

to learn more!

Sincerely, Sagar Lonial, MD Professor Vice Chair of Clinical Affairs Department of Hematology and Medical Oncology Winship Cancer Institute Emory University School of Medicine Atlanta, GA

Director, Quality Control Barbara Marino Director, Production & Manufacturing Alaina Pede Director, Creative & Design Robyn Jacobs Creative & Design Assistant Lora LaRocca Director, Digital Media Anthony Romano Web Content Managers David Maldonado Anthony Travean

FACULTY Kenneth C. Anderson, MD Director, Jerome Lipper Multiple Myeloma Center and LeBow Institute for Myeloma Therapeutics Kraft Family Professor of Medicine Harvard Medical School Dana-Farber Cancer Institute, Boston, MA

Tina Flaherty, ANP-BC, AOCN Nurse Practitioner Division of Hematologic Malignancies Dana-Farber Cancer Institute Boston, MA

Houry Leblebjian, PharmD, BCOP Clinical Pharmacy Specialist in MARCH 2013 • VOLUME 4 • NUMBER 2 Hematology/Oncology Dana-Farber Cancer Institute Boston, MA

Digital Programmer Michael Amundsen Senior Project Manager Andrea Boylston Project Coordinators Deanna Martinez Jackie Luma

Supported by educational grants from Onyx Pharmaceuticals and Millennium: The Takeda Oncology Company.

Executive Administrator Rachael Baranoski Office Coordinator Robert Sorensen

This activity is jointly sponsored by Medical Learning Institute Inc and Center of Excellence Media, LLC.

Center of Excellence Media, LLC 1249 South River Road - Ste 202A Cranbury, NJ 08512

Discussions in Personalized Treatment for Lymphoma: Do We Have Consensus? CONTRIBUTING FACULTY Chair Stephanie A. Gregory, MD

The Elodia Kehm Chair of Hematology Professor of Medicine Director, Lymphoma Program Rush University Medical Center/Rush University Chicago, IL

Sonali M. Smith, MD

Associate Professor Section of Hematology/Oncology Director, Lymphoma Program The University of Chicago Medical Center Chicago, IL

Mitchell R. Smith, MD, PhD Director of Lymphoid Malignancies Program Taussig Cancer Institute Cleveland Clinic Cleveland, OH

2014 PROSPECTUS

Steve M. Horwitz, MD

Assistant Attending Medical Oncologist Lymphoma, Cutaneous Lymphomas, T-Cell Lymphoma Memorial Sloan-Kettering Cancer Center New York, NY

Supported by an educational grant from Celgene Corporation

This activity is jointly sponsored by Medical Learning Institute Inc and Center of Excellence Media, LLC.

YEAR ANNIVERSARY

FIFTH ANNUAL

Navigation and Survivorship Conference SEPTEMBER 18-21, 2014 WALT DISNEY WORLD DOLPHIN HOTEL ORLANDO, FLORIDA

www.AONNonline.org

Scan Here to Register To use 2D barcodes: Visit the app store to download a QR Code reader for your smartphone

lynxcmeAsize_021714

May/june 2014 I VOL 7, NO 3

Services and director of Cytogenomics and Molecular Pathology, Washington University School of Medicine, Saint Louis, Missouri. His presentation specified the following challenges in cancer diagnosis: 1. Sample procurement and analytic issues: samples vary in quantity, quality, and purity 2. Almost all diagnostic cancer biopsies are formalin-fixed, paraffin-embedded (FFPE) tissue 3. Complexity of cancer genomes 4. Heterogeneity of genomic aberrations (abnormalities found at low levels) Dr Kulkarni’s facility is focused on patient care, cost-effectiveness, and ascertaining the right drug at the right dose for the right patient at the right time. Due to funding requirements, he focuses on the clinically actionable genes in cancer cells that have prior payer approval for reimbursement. David S. Hoon, PhD, chief of Scientific Intelligence and director of Molecular Oncology at the John Wayne Cancer Institute, Santa Monica, California, presented information concerning circulating cell-free DNA (cfDNA) and circulating tumor cells (CTCs) in the blood of cancer patients. He discussed how the detection, prognostic, and predictive value of circulating cfDNA analysis is more powerful than protein assay and that it requires no repetitive biopsies but instead uses cfDNA blood tests for monitoring. He questioned the use of tumor samples as to size of the slice and whether the sample covered all the tumor and possible variants. He discussed several factors regarding CTCs: CTCs are shed into the vascular system depending on doubling time, which is a major unknown factor; CTCs occur at low molecular levels in blood; and methods exist to authenticate low-level validations. Also, there would be fewer CTCs in early-stage disease, thus requiring more sampling than at stage III or stage IV. However, he concluded each has its own merit— cfDNA for evidence of tumor or CTCs confirming a metastasized event. During the AACR meeting, I was invited, along with the advocates participating in AACR’s Scientist↔Survivor Program, to attend “Night at the Lab” at Scripps Research Institute to see firsthand what happens in a cancer research lab. Peter Kuhn, PhD, confirmed that CTCs exist in the peripheral blood of cancer patients in low concentrations, making their isolation and identification a difficult task. However, their lab has developed a reliable way to detect and characterize CTCs isolated from the blood of cancer patients—a step toward www.TheOncologyNurse.com

Through the Eyes of an Advocate ultimately reaching the goal of making cancer a managed disease. It was an eventful evening that included an interactive session with physicians, advocates, and scientists discussing ways to navigate treatment pathways and biological pathways. In addition, advocates were placed in small groups and escorted to the lab rooms by one of the researchers, who described the facility and answered questions. When I contacted Dr Kuhn about Dr Hoon’s comments in reference to CTCs, he responded, “Solid tumors often have direct access to the blood supply through tumor vascularization, which in many cancers is disregulated to provide the tumor with additional blood supply for growth. This process also allows for tumor-derived cells to enter the blood circulation. These cells can serve as a liquid biopsy and be used to characterize the disease at many time points along

Laura MacConaill, PhD, shared the importance of standardizing the quality of tissue collection throughout the system. the path of the disease evolution. Many but not all tumors shed cells into the blood, and not all of these cells survive. While generally an increased metastatic tumor burden results in more cells in the circulatory system, there is increasing evidence that some patients with seemingly early-stage disease also have cells in the circulation. This observation also makes sense in the description of the continuum of disease evolution in which one would expect cells to exist in the blood prior to clinically evident distant metastasis.”

He concluded, “Establishing both the broader biological context and the patient-specific use of these liquid biopsies is under intense study. It has opened new fields of rare cell biology that can indeed provide quantitative insights into the temporal evolution of the disease in patients under treatment pressures. The liquid biopsies will be an important complement to current standard of care diagnostic, prognostic, and predictive methods in patient care. The main advantage is of course the ability of directly accessing tumor tissue at

multiple, clinically relevant time points to aid in the treatment decision-making process.” Laura MacConaill, PhD, scientific director, Center for Cancer Genome Discovery, Dana-Farber Cancer Institute and scientific director, Brigham and Women’s Hospital, Boston, Massachusetts, addressed not only the quality of tissue samples but also the collection process. Stressing the significance of matching patient personalized cancer treatment to the driver mutation, she shared the importance of standardizing the quality of tissue collection throughout the system, indicating that currently 33% of samples are of low quality, inadequate, and/or too small. Possibly, in the past, the need for standardization was not as major an issue as it is today, but the world of genomic science has changed this fact. Standards Continued on page 20

Side Effects Management

Skin Toxicity With Targeted Agents Wayne Kuznar

eactive management and attention to possible infection is usually sufficient to treat dermatologic toxicities associated with targeted cancer therapies, said Barbara Burtness, MD, professor of medical oncology at Fox Chase Cancer Center in Philadelphia, Pennsylvania. With epidermal growth factor receptor (EGFR) inhibitors, treating skin toxicity is preferred over suspending the agent, because the development of rash is associated with better efficacy and outcome, she said at the 2014 annual conference of the National Comprehensive Cancer Network. Although rash as a toxicity of EGFR inhibitors may look like acne, it is actually a mixed inflammatory infiltrate with follicular rupture. In general, these infiltrates are sterile, and the Propionibacterium that causes acne is not recovered from skin biopsies. “We also see quite a lot of xerosis,” she said. “This again is associated with a mixed perivascular infiltrate; there are alterations in the stratum corneum, you can see parakeratosis, the keratinocytes can be apoptotic, and the eccrine glands can be miniaturized.” Pustular Rash and Other Skin Toxicities Skin lesions are most common on the face, chest, and back. Rash develops early, whereas paronychia and fissures are later events. Red papulopustules affecting the face and upper body develop in 45% to 100% of patients treated with EGFR inhibitors, usually occurring within 8 to 10 days and peaking at 2 weeks. Before these lesions appear, patients may be aware of sensory disturbance, erythema, and edema, Burtness noted. The telangiectatic phase occurs late (at approximately 6 weeks) and may be hastened by the use of topical steroids and retinoids. In patients treated with EGFR inhibitors, there is evidence that the intensity of their rash correlates with outcomes. For example, patients with colorectal cancer who were treated with cetuximab and who developed

www.TheOncologyNurse.com

prominent rash had better overall survival than those who developed minimal rash, underscoring the importance of managing rash to enable patients to stay on treatment, said Burtness. Severe rash, however, does adversely affect quality of life. Skin toxicities related to EGFR inhibitor therapy can lead to bacterial, viral, or fungal infectious complications in about one-third of patients. Bacterial superinfection (ie, impetigo, dissecting cellulitis) can be severe, she said. Fissures are a late, postinflammatory symptom. They respond to topical steroids. Larger fissures may benefit from cyanoacrylate adhesive dressing, but liquid bandage treatments should be avoided because they may ooze into the fissure, preventing complete closure. Periungual and nail alterations, which develop in 12% to 16% of patients treated with EGFR inhibitors, usually occur 4 to 8 weeks after therapy and can progress to paronychia. Burtness recommends starting treatment with topical steroids; culture with evidence of superinfection and begin antibiotics as indicated. Early alopecia presents as mixed inflammatory infiltrate. Late alopecia is usually nonscarring and is associated with hair changes, such as hair curling and brittle hair. Clobetasol shampoo is “worth trying” and is more helpful in the early stage when rash and crusting are more prevalent, she said. Acitretin 10 mg/day and isotretinoin 30 to 40 mg/ day have been used for EGFR inhibitor skin reactions with success. “Even though lesions don’t resolve, they become more telangiectatic and less pustular,” she said. “There has been some interest in the possibility of using prophylactic treatment to protect patients from these complications with agents known to have a very high rate of rash,” she said. Prophylaxis with systemic minocycline reduced the number of facial lesions compared with placebo in patients treated with cetuximab. In patients with metastatic colorectal cancer treated with panitumumab, prophylactic use of oral antibiotics

with topical steroids was associated with significantly fewer grade 2 or higher skin toxicities compared with reactive treatment (62% vs 29%, respectively). However, the incidence of any-grade nausea and vomiting was higher with prophylactic treatment, although diarrhea was worse with reactive treatment (any-grade diarrhea, 85% for reactive vs 56% for prophylactic; grade 3 diarrhea, 32% vs 15%). Ocular Complications Ocular side effects also occur with EGFR inhibitors. Blepharitis usually responds to warm compresses, lid hygiene with antibacterial eye cleansers, and a short course of a topical eye ointment. Other complications include conjunctivitis, trichomegaly, corneal erosion, dry eye, and ectropion. Dysfunctional tear syndrome is the most common tear film change, and while the use of artificial tears and topical anti-inflammatory agents can be helpful, topical steroids should not be used without involvement of an ophthalmologist, advised Burtness. Skin Toxicity With RAF Inhibitors Emergence of new skin cancers—melanomas in non– sun-exposed areas and squamous cell cancers in sunexposed areas—is a skin manifestation of vemurafenib and regorafenib. Granulomatous eruptions are also possible and respond to topical steroids; unlike the skin lesions associated with EGFR inhibitors, these eruptions are not pustular. Profound hand-foot syndrome has been associated with regorafenib. In addition, atypical melanocytic nevi and Stevens-Johnson syndrome or toxic epidermal necrolysis have been reported in some patients treated with RAF inhibitors. l Reference

Burtness B. Targeted agents: management of dermatologic toxicities. Presented at: 19th Annual Conference of the National Comprehensive Cancer Network; March 13-15, 2014; Hollywood, FL.

May/June 2014 I VOL 7, NO 3

FIFTH ANNUAL

Y E AR A N N I V E R S A RY

Navigation and 5 Survivorship Conference YEAR

A N N I V E R S A RY

September 18-21, 2014 Walt Disney World Dolphin Hotel • Orlando, Florida

TO DATE, THE CONFERENCE HAS HAD MORE THAN:

1,700

Total Attendees

Abstracts

Thank you again for a wonderful conference on the conference to my administration each year to help me get funding for the following year and so far...so good. I attend various national conferences throughout the year and stand amazed at your ability to continue

Expert Speakers

60 Abstracts Submitted

(only missed your first year). I submit a report

to provide new and motivating presentations. – 2013 Conference Attendee

93%

108

93% of 2013 conference attendees said they intended to change their practice as a result of participating in the AONN+ Conference

50 40 30 20

20 10 0

9 2010

2011

2013

2012

Year of Submission

“WOW! I am so impressed with the growth of AONN. Lillie, Sharon, and their team are awesome. The speakers were knowledgeable about their subject matter and all the presentations were relevant to my practice. I will use the pearls of wisdom shared by the speakers to my team at

97%

97% of 2013 conference attendees rated the AONN+ Conference as Above Average or Excellent when compared with other continuing education activities

home. I arrived feeling we have a pretty good program and I am leaving with ideas to share to make it even better!” – Donna Moore Wilson, BSN, RN, CBCN Oncology Nurse Navigator Bon Secours Cancer Institute Richmond, Virginia

AONN+ K-SIZE_11614

May/june 2014 I VOL 7, NO 3

www.regonline.com/AONN2014

www.TheOncologyNurse.com

Healthcare and Insurance

The ACA and Implications for Oncology Care Wayne Kuznar

he Affordable Care Act (ACA) is in its infancy, but the ACA is already changing oncology practice, said panelists during a roundtable discussion at the 2014 conference of the National Comprehensive Cancer Network (NCCN). The changing composition of oncology patients, the risk pool of the exchanges, new payment and reimbursement models, acquisition fever, and oncology workforce demands were the real and potential consequences of the ACA discussed during the roundtable. Forming the panel were moderator Clifford Goodman, PhD, senior vice president and principal, the Lewin Group, Falls Church, Virginia, and panel members: • Christian G. Downs, JD, MHA, executive director, Association of Community Cancer Centers • Elizabeth Fowler, PhD, JD, vice president of global health policy, Johnson & Johnson • Michael Kolodziej, MD, national medical director of oncology strategy, Aetna • Lee N. Newcomer, MD, MHA, senior vice president of oncology, genetics and women’s health, UnitedHealthcare • Mohammed S. Ogaily, MD, medical director, Oakwood Center for Hematology and Oncology– Downriver; president, Michigan Society of Hematology and Oncology • W. Thomas Purcell, MD, MBA, associate director for clinical services, University of Colorado Cancer Center, Denver; executive medical director of oncology services, University of Colorado Hospital • John C. Winkelmann, MD, private practice physician, Oncology & Hematology Care, Cincinnati, Ohio Patient Demographics Since the rollout of the ACA, the composition of patients with cancer has not changed from the perspective of risk, said Purcell, but many patients covered by commercial insurance are for the first time participating in a narrow network. In addition, many patients who qualify for Medicaid and those selecting Bronze ACA plans have large co-pays and more out-of-pocket expenses than they did before, and managing these expenses will be challenging. The narrowing of networks has also had the consequence of interrupting continuity of care for some patients. “We’re getting situations in which patients are unable to come to us because they’re in a particular narrow network that we don’t cover,” he said.

www.TheOncologyNurse.com

Patients with rare or complex cancers best managed by an academic medical system that delivers multidisciplinary care may therefore not receive optimal management if the academic medical center is outside the patient’s narrow network, Purcell said, “unless he pays out of pocket or we make an exception to treat him and cover the cost.” Patients with immediate needs for care that could not be addressed previously are presenting at his clinic, said Ogaily. “Certainly, some [patients] are more complex because of the time that they have lacked coverage and did not seek medical care,” he said. When asked where the ACA falls short, Newcomer mentioned the medical necessity clauses that prohibit taking cost into consideration when balancing treatment options that deliver equal outcomes. “You have in any NCCN guideline multiple options for adjuvant breast cancer therapy or the treatment of non–small cell lung cancer. Some of them are far less expensive than others, but they have the same end results and often may have the same toxicities. In those scenarios, we should be thinking about using lower cost alternatives,” he said. “We’re not allowed to do that in Medicare or the ACA.” Risk Pool Uncertainty In this early stage of the ACA, the risk pool is uncertain, creating a quandary for insurers, the panelists agreed. Because enrollment in ACA by younger persons is lagging, insurers may have insufficient data to make premium bids for next year, said Fowler. “If the risk pool stays risky, does the thing fall apart?” asked Goodman.

to comply with new regulations. Said Newcomer, “It has been an extremely expensive product to roll out. It takes a lot of our time, energy, and resources to keep making all of the changes that occur. It takes money away from other innovative programs.” “One of the things that you’re start-

“We’re seeing as much as a 10-fold increase in the price of a drug if a community practice is acquired by a hospital or facility.” Lee N. Newcomer, MD, MHA

ing to see is provider networks looking at doing things like accountable care organizations [ACOs], oncology medical homes, and broad medical homes,” said Downs. “I do worry a little bit though about providers’ going-in risk, because that’s very difficult to manage and it’s not necessarily their area of expertise. There is some concern about providers going too quickly into models they don’t fully understand.” Ogaily said that although ACOs are sprouting up in Michigan, the enthusiasm for oncology medical homes has not been robust. More Integrated Networks The new payment and reimbursement models with a shared savings environment will favor independent or group practitioners who have established rela-

Since the rollout of the ACA, the composition of patients with cancer has not changed from the perspective of risk...but many patients covered by commercial insurance are for the first time participating in a narrow network.

Certain adjustments, such as a temporary reinsurance program, a temporary risk corridor program, and a permanent risk adjustment program may be necessary, according to Fowler. Other adjustments to the ACA, such as delaying the individual mandate, have been expensive to insurers as they continually reprogram their systems

noting the large number of disciplines involved in cancer care. The ACA may facilitate integration with its mandates for quality care measures and reporting requirements. Razor-thin margins owing to lower government reimbursement for oncology treatments are expediting hospital

tionships with payers, while putting at risk the practices that are not well integrated, said Downs. Acquisitions of oncology group practices and hospital mergers may be the new norm, a trend that started with the Medicare Modernization Act, he said. “The concept of an integrated network becomes very important,” he said,

acquisition of physician practices, which are finding it difficult to survive on these low margins, said Newcomer. The consequence is an increase in prices as hospitals use their expanded leverage to negotiate fees. “We’re seeing as much as a 10-fold increase in the price of a drug if a community practice is acquired by a hospital or facility,” he said. “That’s 10-fold on drugs that are not cheap in the first place. The patients pay for that with their co-payments and deductibles…and we also have to raise premiums to cover it.” “One of the consequences of healthcare reform stimulated by the ACA is the requirement that, irrespective of site of service, you become sensitive to your price point and sensitive to quality metrics because network management is part of the strategy,” said Kolodziej. The rapid rate of consolidation has resulted in less opportunity to negotiate appropriate site-of-service payment rates (ie, site-of-service differential), he added. The cost differential between a community practice and large hospital system may not reflect differences in services but “winds up being a contracting issue,” he said. Even though the site of care, the services, and the patients may not change when a hospital system acquires a community oncology practice, “the fee schedules convert to the hospital’s negotiated fee schedule, which would be typically higher than we can get in community physician-based clinics,” said Newcomer. The high rate of acquisition of community practices also runs the risk of leaving remote areas inadequately covered because larger hospital systems tend to focus on large metropolitan areas, said Continued on page 17

May/June 2014 I VOL 7, NO 3

Nutrition in Focus

Nutrition in the Multidisciplinary Team: Risk Identification and Intervention Tiffany DeWitt, MS, MBA, RD, LD, Abbott Nutrition

he definition of quality care is continuing to evolve in the oncology clinic. Emphasis is being placed on providing holistic care to patients through a multidisciplinary care team approach. The delivery of healthcare goes beyond treating the immediate disease—in our case, cancer—to recognizing and treating the whole individual medically, emotionally, financially, and physically. To successfully deliver holistic care, all clinical caregivers must actively participate within the multidisciplinary team to identify unique patient needs and direct care that provides appropriate guidance and solutions for the patient. Nutrition education is recognized as a patient need that, when provided, can help with patient satisfaction.1 The importance of nutrition services and education has been recognized by leading oncology associations and is now a required part of patient care (Table).2-5 The American College of Surgeons Commission on Cancer released its Cancer Program Standards 2012: Ensuring Patient-Centered Care, which indicates that a policy must be in place to allow access for nutrition services, either on-site or by referral.4 The Association of Community Cancer Centers also published guidelines recommending that patients and their families have access to a nutrition professional.3 Multidisciplinary team member involvement in nutrition services will vary depending on the nutritional needs of the oncology patient being treated. A registered dietitian (RD) is an integral part of the team, but all clinicians, including physicians and nurses, must be able to proactively identify patients at nutritional risk, or with nutrition-related concerns, to recommend an appropriate intervention. Standing orders for nutrition screening can be integrated into the patient care process to allow all clinicians to participate as necessary. Outpatient clinics that have already incorporated nutrition into patient care have demonstrated success through alleviating patients’ distress and improving their nutritional status.6,7 A pilot study of a Cancer Nutrition and Rehabilitation program demonstrated significant improvement in strength, appetite, constipation, and shortness of breath in 53 patients with gastroesophageal cancer who participated in an 8-week multidisciplinary program that included nutritional support.6 The program used the PatientGenerated Subjective Global Assessment (PG-SGA) and the Edmonton Symptom Assessment Scale (ESAS), along with

May/june 2014 I VOL 7, NO 3

other questionnaires, to identify the unique needs of individual patients, such as the need to improve appetite,

THIRD

increase energy, or decrease symptoms of depression or anxiety.6 Depending on the results, the patients received interven-

tions from various clinicians, including, but not limited to, physicians, nurses, Continued on page 19

ANNUAL CONFERENCE

GLOBAL BIOMARKERS Clinical Approaches to CONSORTIUM Targeted Technologies ™

™

October 31 – November 1, 2014 • Marriott Marquis • San Francisco, CA

CONFERENCE CHAIRS Jorge E. Cortes, MD

Chair, CML and AML Sections D.B. Lane Cancer Research Distinguished Professor for Leukemia Research Department of Leukemia, Division of Cancer Medicine The University of Texas MD Anderson Cancer Center Houston, TX

Roy S. Herbst, MD, PhD

Ensign Professor of Medicine Professor of Pharmacology Chief of Medical Oncology Director, Thoracic Oncology Research Program Associate Director for Translational Research Yale Cancer Center, New Haven, CT

CONFERENCE OVERVIEW

The only global meeting dedicated to advancing the understanding of value and clinical impact of biomarker research in oncology. Guided by the expertise of leaders in this ﬁeld, participants will receive a thorough understanding of the current and future landscape of the relevance of tumor biomarkers and how to effectively personalize cancer care in the clinical setting.

TARGET AUDIENCE

This activity has been designed to meet the educational needs of medical oncologists and hematologists, pathologists, geneticists, advanced practice oncology/hematology nurses, research nurses, clinical oncology pharmacists, and genetic counselors involved in the management of patients with solid cancers or hematologic malignancies, and interested in the use of molecular biomarkers to help optimize patient care. Research scientists interested in the ﬁeld of molecular biomarkers in oncology are also invited to participate.

DESIGNATION OF CREDIT STATEMENTS ACCREDITATION STATEMENT

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Postgraduate Institute for Medicine and Center of Excellence Media, LLC. The Postgraduate Institute for Medicine is accredited by the ACCME to provide continuing medical education for physicians.

CREDIT DESIGNATION

The Postgraduate Institute for Medicine designates this live activity for a maximum of 9.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AMERICANS WITH DISABILITIES ACT

Event staff will be glad to assist you with any special needs (ie, physical, dietary, etc). Please contact Linda Sangenito prior to the live event at (732) 992-1520.

DISCLOSURE OF CONFLICTS OF INTEREST

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers, and other individuals who are in a position to control the content of this activity to disclose any real or apparent conﬂict of interest (COI) they may have as related to the content of this activity. All identiﬁed COI are thoroughly vetted and resolved according to PIM policy. The existence or absence of COI for everyone in a position to control content will be disclosed to participants prior to the start of each activity. Jointly provided by Postgraduate Institute for Medicine and Center of Excellence Media, LLC

EDUCATIONAL OBJECTIVES

After completing this activity, the participant should be better able to: • Assess emerging data and recent advances in the discovery of molecular biomarkers on the management of patients with solid tumors and hematologic malignancies •

Discuss the role of molecular biomarkers in designing personalized therapy for patients with solid tumors and hematologic malignancies

•

Outline the practical aspects and value-based considerations of integrating molecular biomarkers into everyday clinical practice in the treatment of patients with cancer

This activity is supported, in part, by independent educational grants from Lilly. For further information concerning Lilly grant funding visit www.lillygrantoffice.com. This activity is also supported, in part, by an educational grant from Prometheus. Current at time of printing.

SUBMIT AN ABSTRACT BY SEPTEMBER 5, 2014 Submit an abstract for the Third Annual Global Biomarkers Consortium. This is an opportunity to share research, programs, and results with your peers. This session will facilitate communication among the various professionals and programs to advance the knowledge of all our members and those in attendance.

www.globalbiomarkersconsortium.com/conference/abstracts

www.TheOncologyNurse.com

Healthcare and Insurance

The ACA and Implications for Oncology Care Ogaily. Traditionally, small community practices have been able to provide coverage to remote areas. Healthcare Demand and the Oncology Workforce The potential effect of a backlog of patient demand created by the ACA on

the hematology and oncology workforce needed to meet this demand was raised by Goodman. When added to the demographic shift in the population, patient volumes may exceed the capability of the supply of hematologists and oncologists, necessitating increased use of physician extenders, said Winkelmann.

AGENDA*

FRIDAY, OCTOBER 31 11:45 am - 2:15 pm Product Theaters 2:15 pm - 2:30 pm

Break

2:30 pm - 2:40 pm

Welcome to the Third Annual Conference of the Global Biomarkers Consortium — Opening Remarks

2:40 pm - 4:15 pm

General Session I: Cancer Care in the Era of Molecular Biomarkers • Personalized medicine in oncology: therapeutic advances from cytotoxic chemotherapy to molecularly targeted agents – Razelle Kurzrock, MD • Understanding cancer at the molecular level – Caroline Robert, MD, PhD • Standardization of molecular biomarker testing – Mark Sausen, MD • Implications of molecular diagnostics on clinical trial design – John J. Wright, MD, PhD Question & Answer Session

4:15 pm - 4:30 pm

Break

4:30 pm - 5:30 pm

General Session II - Part 1: Incorporating Molecular Biomarkers into the Therapy of Solid Tumors — Case Studies on “How I Treat” • Melanoma – Sanjiv S. Agarwala, MD • Breast cancer – Hope Rugo, MD Question & Answer Session

5:30 pm - 7:00 pm

Welcome Reception and Exhibits

11:05 am - 12:00 pm Keynote Lecture: Markers of Resistance to Targeted Therapies – Alberto Bardelli, PhD Question & Answer Session

Product Theater

8:00 am - 8:15 am

Break

8:15 am - 8:30 am

Review of Friday’s Presentations and Preview of Today

8:30 am - 9:30 am

General Session II - Part 2: Incorporating Molecular Biomarkers into the Therapy of Solid Tumors — Case Studies on “How I Treat” • Melanoma – Sanjiv S. Agarwala, MD • Colorectal cancer – Axel Grothey, MD Question & Answer Session

9:30 am - 9:45 am

Break

9:45 am - 11:05 am General Session III: Incorporating Molecular Biomarkers into the Therapy of Hematologic Malignancies — Case Studies on “How I Treat”

1:00 pm - 1:15 pm

Break

1:15 pm - 2:00 pm

Tumor Board Breakout Sessions • Attendee cases in solid tumors • Attendee cases in hematologic malignancies

2:00 pm - 2:15 pm

Break

2:15 pm - 3:30 pm

General Session IV: Molecular Biomarkers for the Early Detection of Cancer: Are They Ready for Prime Time? • Developing and validating biomarkers via the Early Detection Research Network (EDRN-NCI) – Sudhir Srivastava, PhD, MPH • Beyond PSA: novel molecular biomarkers for prostate cancer – Mark Rubin, MD • Airway biomarkers for lung cancer detection in the post-NLST era – Avi Spira, MD, MSc • Early detection biomarkers for breast cancer – Karen Anderson, MD, PhD Question & Answer Session

3:30 pm - 3:45 pm

Break

3:45 pm - 4:00 pm

Keynote Lecture: Actionable Genomic Alterations in Oncology – Phil Stephens, PhD

4:00 pm - 4:50 pm

General Session V: Regulatory and Economic Aspects of Personalized Medicine in Oncology • Understanding the regulatory aspects of personalized medicine in oncology – Andrew Stainthorpe, PhD • A debate on health economics and molecular biomarkers: can we afford personalized medicine in oncology? – Gary Johnson, MD, MS, MBA, and Ken Schaecher, MD, FACP, CPC Question & Answer Session

4:50 pm - 5:00 pm

Closing Remarks

Newcomer. Physicians may be the ones directing care and devising treatment plans, with extenders administering treatments. The physician may then be involved only in the case of toxicity. “If we rethink it, we can solve the problem, but it needs changing the financing and needs changing how we work with all of our other ancillary providers that care for cancer patients,” he said. “It can be done, but we’ll have to be innovative, and that’s the reason that all of us are toying with new ways of paying for cancer care. Whether it be episodes, bundles, or capitation, we’re trying to find a way to realign the incentives to help physicians and hospital communities restructure how they deliver that care. The quicker we can get to that, the better off we’ll all be.” Provisions under the ACA were geared toward moving providers from a fee-for-service system that warrants volume to one that values outcomes and quality instead, said Fowler. “It’s a rough transition, particularly for providers that weren’t prepared or didn’t have the technology in place to do this,” she said. Thirty percent of reimbursement incentives are based on patient satisfaction, Fowler continued. “When you are thinking about what you need to do to meet the quality measures, you’ve got to start thinking about what matters to patients. That might be where survivorship and other issues come into play.” l Reference

*Agenda subject to change. GBC2014ConfAd Asize_60914

www.TheOncologyNurse.com

Provisions under the ACA were geared toward moving providers from a fee-for-service system that warrants volume to one that values outcomes and quality instead.

12:00 pm - 1:00 pm Meet the Experts and Lunch in the Exhibit Hall

SATURDAY, NOVEMBER 1 7:00 am - 8:00 am

Other specialties are scrambling to add physician extenders as well, creating competition for their services. “We’ve got to start over and figure out how we can meet the needs of this large group of cancer patients coming forward into the system. That means a whole different way of approaching care,” said

• Myeloid hematologic malignancies – Jorge E. Cortes, MD • Chronic lymphocytic leukemia – William Wierda, MD, PhD • Multiple myeloma – Sagar Lonial, MD • Lymphoma – Anas Younes, MD

7:00 am - 12:00 pm Registration

Continued from page 15

Goodman C. The Affordable Care Act: where are we now? [roundtable discussion]. Presented at: 19th Annual Conference of the National Comprehensive Cancer Network; March 14, 2014; Hollywood, FL.

May/June 2014 I VOL 7, NO 3

Genetic Counseling

A Historical Overview of the Evolving Landscape…

Cristi Radford, MS, CGC

genetics clinics hoped to gain an understanding of the genetics involved in disease. At that time, however, laboratory tests for genetic conditions did not exist and the practice of genetic counseling was limited. During the 1950s and 1960s, cytogenetics advanced and amniocentesis emerged, making it possible for physicians to diagnose chromosomal abnormalities in their patients. Additionally, amniocentesis could be used to detect Barr bodies in fetal cells, allowing the prediction of fetal sex.2 This information could then be applied to families at risk for a sex-linked genetic disorder. Eventually, by the mid-1960s, amniocentesis was used to construct a human karyotype of the fetus.3 Amniocentesis did not come without risks, however; not only did the information from amniocentesis have to be conveyed to the family but the risks, limitations, and benefits of the procedure had to be explained to them as well. Medical professionals realized that conveying genetic information required a particular subset of skills, and the first genetic counseling programs came into being. With the expanded use of genetics in medicine, genetic counseling was no longer limited to a few specialty centers, and the number of centers offering genetic counseling services grew from 10 in 1951 to 287 in 1977.4 As science progressed into the 1980s, advances were seen in cytogenetics, molecular genetics, and biochemical genetics. The role of the genetic counselor in the prenatal setting expanded to include providing information obtained from examining enzymes in amniotic fluid.5 Additionally, genetic counselors entered predisposition testing when the gene for Huntington’s disease was mapped with DNA markers.6 Predisposition testing continued to grow in the 1990s as several cancer-predisposing genes were cloned. Mutations in these genes were shown to cause an increased risk for cancers, such as colon, breast, and ovarian.7 As centers began offering predictive DNA testing to affected individuals and family members at risk, genetic counselors

May/june 2014 I VOL 7, NO 3

entered a new sector: cancer counseling. The sequencing of the human genome and identification of cancer predisposition genes, such as BRCA1 and BRCA2, rapidly increased the need for individuals with cancer genetic expertise and experience in genetic counseling. Additionally, direct-to-consumer marketing of hereditary cancer genetic testing and celebrities announcing their own BRCA status have furthered society’s awareness of genetic testing. In turn, healthcare professionals have faced increased pressure to incorporate genetic testing into their practice—either by providing in-house genetic counseling or referring to experts for consultation. Over the last decade, genetic testing has increasingly been performed through community practitioners without the involvement of a trained genetics professional.8 In addition to increased awareness, the landscape of cancer genetic testing has also been impacted by technological advances and policy decisions.

Tuya Pal, MD, FABMG

Since the discovery of BRCA1/2, there have been tremendous advances in DNA sequencing technologies. In 2003, the Human Genome Project completed its version of the human genome sequence, which took approximately 15 years of research and cost $2.7 billion.9,10 However, over the last few years, the cost of generating sequencing data has dropped to less than $10,000 and takes a matter of a few weeks.11 It is anticipated that costs will drop below $1000 and take just days (potentially hours) to complete, recognizing, of course, that this does not factor in the time and cost needed for interpretation and return of the results to the patient. Such changes have resulted in expanded testing options for inherited cancer, with the paradigm for genetic testing expected to change as well. Since 2012, multigene tests have been available on a clinical basis. These tests allow for multiple genes to be analyzed for mutations simultaneously, at a cost that is often comparable to testing for a single inherited condition. No longer does a clinician have to rely on a genetic testing strategy focused on eliminating

differential diagnoses, but he or she can begin with a multigene test incorporating many genes linked to a particular cancer site. However, at the same time, the clinician will also be faced with a higher likelihood of receiving a variant of unknown significance, an incidental finding, and/ or a gene mutation for which medical guidelines have not yet been determined. As a result of technological changes, cancer genetic counseling continues to evolve. Multigene tests allow a clinician to cast a wider net and analyze several to hundreds of genes. Clinicians can even opt to select for genes outside of the inherited cancer arena. The traditional model for delivering cancer genetic counseling services begins with an in-person pretest genetic counseling session followed by a results disclosure session, both conducted by a certified or credentialed genetics professional trained to provide a detailed risk assessment that includes a differential diagnosis, education, and medical management options for hereditary cancer.12 Such an approach is often not feasible when genetic testing involves a multigene test, and the optimal approach is currently unknown.13 Counseling strategies appear to be shifting toward one that relies on a broad pretest session that covers topics essential for informed consent, such as conditions being tested for and possible genetic test results, but that defers detailed discussion of specific conditions to the posttest session, during the disclosure of genetic test results.14 The ruling in June 2013 by the Supreme Court of the United States, which concluded that genes could not be patented,15 further changed the marketplace for genetic testing. At the time, approximately 20% of human genes were patented,16 including BRCA1 and BRCA2. Upon the Supreme Court’s decision, several laboratories immediately added BRCA1/2 to their testing menu and included it on their multigene panels. As a result, clinicians were able to use a single panel to search for mutations in multiple genes linked to inherited breast and/or ovarian cancer rather than relying on multiple laboratories and tests for comprehensive analysis. It is interesting to note that multigene panels are providing more insight into the phenotypes of hereditary cancer syndromes. Indeed, several studies have found patients with germline mutations that do not meet classic testing criteria and which would likely have been missed if testing relied on a single-gene testing approach.17-20 With the significant decreases in the cost of genotyping, it is not unreasonable to postulate that individuals may one day undergo full exome or genome analysis not only to determine which medical conditions they are at risk for, but also

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for pharmacogenomic applications. It is important to remember that genetics is different from other topics in medicine as it underlies all of pathophysiology and will likely increasingly influence healthcare as technology continues to evolve. The shift to multigene testing options is the first step in that direction. With these technological advances enabling more individuals to be identified as being at risk, however, the complexities of delivering genetic services and managing genetic risk will also be magnified. As such, genetic counseling for inherited disease, such as cancer, must continue to evolve. l

References

1. Reed SC. Counseling in Medical Genetics. Philadelphia, PA: WB Saunders Co; 1955. 2. Fuchs F, Riis P. Antenatal sex determination. Nature. 1956;177(4503):330. 3. Steele MW, Breg WR Jr. Chromosome analysis of human amniotic-fluid cells. Lancet. 1966;1(7434):383385. 4. Marks JH. Masters level training programs for genetic counselors: an eight year report. In: Hook EB, Porter IH, eds. Service and Education in Medical Genetics. New York, NY: Academic Press; 1979:351-360. 5. Boué A, Muller F, Nezelof C, et al. Prenatal diagnosis in 200 pregnancies with a 1-in-4 risk of cystic fibrosis. Hum Genet. 1986;74(3):288-297. 6. Gusella JF, Wexler NS, Conneally PM, et al. A polymorphic DNA marker genetically linked to Huntington’s disease. Nature. 1983;306(5940):234-238. 7. Offit K. Clinical Cancer Genetics: Risk Counseling and Management. New York, NY: Wiley-Liss Inc; 1998. 8. Keating NL, Stoeckert KA, Regan MM, et al. Physician’s experiences with BRCA1/2 testing in community settings. J Clin Oncol. 2008;26(35):5789-5796. 9. International Human Genome Sequencing Consortium. Finishing the euchromatic sequence of the human genome. Nature. 2004;431(7011):931-945. 10. National Human Genome Research Institute. The Human Genome Project completion: frequently asked questions. http://www.genome.gov/11006943. Updated October 30, 2010. Accessed May 29, 2014. 11. Phimister EG, Feero WG, Guttmacher AE. Realizing genomic medicine. N Engl J Med. 2012;366(8):757-759. 12. Pal T, Radford C, Vadaparampil S, et al. Practical considerations in the delivery of genetic counseling and testing services for inherited cancer predisposition. Community Oncol. 2013;10(5):147-153. 13. Domchek SM, Bradbury A, Garber JE, et al. Multiplex genetic testing for cancer susceptibility: out on the high wire without a net? J Clin Oncol. 2013;31(10):1267-1270. 14. Radford C, Prince A, Lewis K, et al. Factors which impact the delivery of genetic risk assessment services focused on inherited cancer genomics: expanding the role and reach of certified genetics professionals [published online ahead of print December 4, 2013]. J Genet Couns. doi:10.1007/s10897-013-9668-1. 15. Park S. VICTORY! Supreme Court decides: our genes belong to us, not companies. American Civil Liberties Union website. https://www.aclu.org/blog/ womens-rights-free-speech-technology-and-liberty/ victory-supreme-court-decides-our-genes-belong. Published June 13, 2013. Accessed May 29, 2014. 16. American Civil Liberties Union. ACLU challenges patents on breast cancer genes: gene patents stifle patient access to medical care and critical research [press release]. https://www.aclu.org/free-speech-wom ens-rights/aclu-challenges-patents-breast-cancer-genes. Published May 12, 2009. Updated May 14, 2009. Accessed May 29, 2014. 17. Cragun D, Radford C, Dolinsky JS, et al. Panelbased testing for inherited colorectal cancer: a descriptive study of clinical testing performed by a US laboratory [published online ahead of print February 9, 2014]. Clin Genet. doi:10.1111/cge.12359. 18. Pennington KP, Walsh T, Lee M, et al. BRCA1, TP53, and CHEK2 germline mutations in uterine serous carcinoma. Cancer. 2013;119(2):332-338. 19. Walsh T, Casadei S, Lee MK, et al. Mutations in 12 genes for inherited ovarian, fallopian tube, and peritoneal carcinoma identified by massively parallel sequencing. Proc Natl Acad Sci U S A. 2011;108(44):18032-18037. 20. Kurian AW, Hare EE, Mills MA, et al. Clinical evaluation of a multiple-gene sequencing panel for hereditary cancer risk assessment [published online ahead of print April 14, 2014]. J Clin Oncol. doi:10.1200/ JCO.2013.53.6607.

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Nutrition in Focus

Nutrition in the Multidisciplinary Team… dietitians, physical and occupational therapists, social workers, psychologists, case managers, and chaplains.6 The nutrition status of participants improved at the end of the pilot as demonstrated by an improvement in PG-SGA and ESAS scores.6 A separate retrospective study of patients participating at a half-day symptom-control clinic for advanced cancer patients at MD Anderson Cancer Center revealed improvement in overall wellbeing with the use of a multidisciplinary team that included nutrition services.8 When nutrition screening and intervention is included in multidisciplinary teams, clinicians are better able to serve the unique nutritional needs of oncology patients. The process of including nutrition into patient-centered, multidisciplinary care requires all members of the healthcare team. For example, nurses perform nutrition risk screening, provide nutrition education, and develop relationships to encourage patients to comply with nutrition intake; dietitians perform nutrition assessments to develop individual nutrition interventions when needed; and the physician oversees the entire care plan to ensure complete treatment and documentation to support reimbursement. Holistic care also includes pharmacists, social workers, physical therapists, and other practitioners of integrative medicine to help identify patients with nutrition difficulties, including drug-medication interactions, financial burdens, or physical inability to eat. All healthcare providers should be both knowledgeable about nutrition to be able to identify nutrition risk and empowered to provide effective nutrition intervention as appropriate.9 Such intervention may range from encouraging patients to keep up their daily intake, to educating patients on oral nutrition supplements, to assisting in starting a patient on tube feeding. Different clinicians will be involved in the care depending on the intervention. The oncology nurse is perfectly positioned and trained to provide the initial screening as well as proactive nutrition guidance. Screening for nutrition risk is an important role a nurse can play to identify patients who will benefit from immediate nutrition education, supplemental nutrition intervention, or a referral to a dietitian for further assessment. The Malnutrition Screening Tool (MST) is a simple, validated tool to identify patients with cancer who are at risk of malnutrition (Figure).10,11 The MST is a quick 2- to 3-question screening tool that can accurately identify patients at risk of malnutrition. Nurses have the opportunity to interact with patients more frequently than do most other team members, and by establishing a strong therapeutic relationship with patients and their families

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Table

Continued from page 16

Society Guidelines Recognizing Nutrition Services as Part of the Multidisciplinary Team2,3,5

Society

Recommendation

All patients should have access to the full range of support services and specialists with expertise National Comprehensive 5 in the management of oncology patients for optimal treatment and follow-up. This includes Cancer Network (NCCN) nutrition support.

National Cancer Institute (NCI)2

Screening and nutrition assessment should be interdisciplinary; the healthcare team (eg, physicians, nurses, registered dietitians, social workers, psychologists) should all be involved in nutritional management throughout the continuum of cancer care. Virtually every cancer patient could benefit from consultation with a registered dietitian or physician to formulate a plan for nutrition and to begin meal planning.

A nutrition professional should be available to work with patients and their families, especially patients identified as at risk for having nutritional problems or special needs. The nutrition Association of Community professional, along with the patient, family, and oncology team, should manage issues involving Cancer Centers (ACCC)3 the patient’s nutritional and hydration status through appropriate nutrition screening, assessment, and intervention across the care continuum. Figure Malnutrition Screening Tool Example11 1. Have you lost weight recently without trying? No 0 Unsure 2 2. If yes, how much weight (kilograms) have you lost? 1-5 1 6-10 2 11-15 3 >15 4 Unsure 2 3. Have you been eating poorly because of a decreased appetite? No 0 Yes 1 Total Score __________ Score of 2 or more indicates patient may be at nutrition risk.

The process of including nutrition into patient-centered, multidisciplinary care requires all members of the healthcare team.

while providing direct patient care, the nurse can effectively impact patient management strategies related to nutrition. Currently, the lack of routine nutrition-risk screening leaves more than half of at-risk patients unrecognized and onefourth of at-risk patients without needed nutrition intervention.12 The multidisciplinary team approach is a new opportunity to address the underrecognized problem of malnutrition in the oncology population.13 With nursing providing screening and nutrition intervention at diagnosis, dietitians providing assessment and individual care plans when appropriate, and physicians overseeing the entire

care plan, the entire team can treat the nutritional problems through early nutrition intervention.14 l References

1. Isenring E, Capra S, Bauer J. Patient satisfaction is rated higher by radiation oncology outpatients receiving nutrition intervention compared with usual care. J Hum Nutr Diet. 2004;17(2):145-152. 2. National Cancer Institute. PDQ Nutrition in Cancer Care. Bethesda, MD: National Cancer Institute. http:// cancer.gov/cancertopics/pdq/supportivecare/nutrition/ HealthProfessional. Last modified February 26, 2014. Accessed May 21, 2014. 3. Marino MJ, Patton A, eds. Cancer Nutrition Services: A Practical Guide for Cancer Programs. Rockville, MD: Association of Community Cancer Centers; 2012. 4. Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care, Version 1.2.1.

Tiffany DeWitt, MS, MBA, RD, LD Chicago, IL: American College of Surgeons; 2012. 5. NCCN Guidelines® Updates. J Natl Compr Cancer Netw. 2013;11(9):xxxiv-xxxvi. 6. Chasen MR, Bhargava R. A rehabilitation program for patients with gastroesophageal cancer—a pilot study. Support Care Cancer. 2010;18(suppl 2):S35-S40. 7. Pituskin E, Fairchild A, Dutka J, et al. Multidisciplinary team contributions within a dedicated outpatient palliative radiotherapy clinic: a prospective descriptive study. Int J Radiat Oncol Biol Phys. 2010;78(2):527-532. 8. Bruera E, Michaud M, Vigano A, et al. Multidisciplinary symptom control clinic in a cancer center: a retrospective study. Support Care Cancer. 2001;9(3):162168. 9. Tappenden KA, Quatrara B, Parkhurst ML, et al. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN J Parenter Enteral Nutr. 2013;37(4):482-497. 10. Isenring E, Cross G, Daniels L, et al. Validity of the malnutrition screening tool as an effective predictor of nutritional risk in oncology outpatients receiving chemotherapy. Support Care Cancer. 2006;14(11):11521156. 11. Ferguson M, Capra S, Bauer J, et al. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458-464. 12. Bozzetti F, Mariani L, Lo Vullo S, et al. The nutritional risk in oncology: a study of 1,453 cancer outpatients. Support Care Cancer. 2012;20(8):1919-1928. 13. Leuenberger M, Kurmann S, Stanga Z. Nutritional screening tools in daily clinical practice: the focus on cancer. Support Care Cancer. 2010;18(suppl 2):S17-S27. 14. Kim J-Y, Wie G-A, Cho Y-A, et al. Development and validation of a nutrition screening tool for hospitalized cancer patients. Clin Nutr. 2011;30(6):724-729.

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Best Practices

Maximizing Safety of Chemotherapeutic… Continued from page 5

Erica Hochard, PharmD

therapy after 35 weeks, as well as the potential effect of treatment on future fertility. It is best to have a multidisciplinary team on board for these decisions, she added. What Agents to Avoid? In a nutshell, there are about half a dozen agents that should strictly be avoided during all trimesters: bevacizumab, trastuzumab, high-dose chemotherapy (ie, preparative regimens for transplant), idarubicin (and possibly epirubicin), methotrexate, and tamoxifen. Many other agents are considered relatively safe in the second and third trimesters, but most should be avoided in the first trimester whenever possible, she said. Hochard also shared her list of preferred agents for the common cancers that occur in the pregnant population (Table). With bevacizumab, there is a theo-

retical concern regarding angiogenesis inhibition. With trastuzumab, oligohydramnios has been observed in more than 50% of cases; however, there have been no reports of congenital anomalies or cardiac events. With tamoxifen, reported birth defects have included ambiguous genitalia, Goldenhar syndrome (associated with incomplete development of the ear, nose, soft palate, lip, and mandible), and Pierre Robin sequence (smaller-than-normal lower jaw, tongue that falls back in the throat, and difficulty breathing). Idarubicin has been associated with transient and permanent cardiomyopathy and congenital abnormalities. With methotrexate, there have been cases of aminopterin-like syndrome, skeletal abnormalities, ambiguous genitalia, spontaneous abortion, low birth weight, and pancytopenia. Discussing the taxanes, she noted 12 exposures of which 92% resulted in a healthy newborn. It is theorized that placental P-glycoprotein could prevent transplacental transfer of the drug. Use in the treatment of breast cancer in the second and third trimesters, however, is controversial. Regarding the platinums, cisplatin is preferred over carboplatin. Targeted Agents In addition to trastuzumab and bevacizumab on the “do not give” list, Hochard discussed other targeted agents.

Table

Preferred Chemotherapy Agents During Pregnancy

Type of Cancer

Preferred Regimen

Breast

Doxorubicin + cyclophosphamide ± 5-FU (in 2nd and 3rd TMs)

Acute leukemia

1st TM: consider termination of pregnancy AML 2nd or 3rd TM: 7 + 3 regimen ALL >20 weeks: modified protocol until 3rd TM

Hodgkin lymphoma

ABVD or single-agent vinblastine

Non-Hodgkin lymphoma

Regimens containing cyclophosphamide, doxorubicin, vincristine (CHOP, CVP); rituximab is probably acceptable

Ovarian Chronic myelogenous leukemia Cervical

Observation or single-agent platinum; if advanced disease, sequential taxane Continue imatinib if patient becomes pregnant during therapy; if initiating treatment, consider hydroxyurea or interferon during 2nd or 3rd TM Consider delaying treatment until baby is mature enough for delivery

Abbreviations: ABVD, doxorubicin hydrochloride, bleomycin, vinblastine sulfate, dacarbazine; ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; CHOP, cyclophosphamide, doxorubicin, vincristine, prednisone; CVP, cyclophosphamide, vincristine, prednisone; 5-FU, 5-fluorouracil; TM, trimester.

She noted that rituximab is believed to be relatively safe but may suppress B cells; no cases of fetal morbidity or mortality have been reported. Alemtuzumab has shown no adverse reproductive effects in animal studies. Patients receiving cetuximab and panitumumab have shown some increased risk of weight loss and spontaneous abortion. Imatinib should not be the drug of choice for initiating therapy for chronic

myelogenous leukemia, but if patients become pregnant while on this therapy, it should be continued due to the risk of disease progression, Hochard indicated. l Reference

Hochard E. The use of chemotherapy during pregnancy: clarifying the conundrum. Presented at: 10th Annual Conference of the Hematology/Oncology Pharmacy Association; March 26-29, 2014; New Orleans, LA.

Through the Eyes of an Advocate

The New Bold Frontier of the “War on Cancer” from labs can vary greatly, affirming the need for the Clinical Laboratory Improvement Amendments (CLIA) program. CLIA labs are required to be certificated by their state as well as by the Center for Medicare and Medicaid Services (CMS) before they can accept human samples for diagnostic testing. Three federal agencies are responsible and have unique roles in assuring quality laboratory testing for CLIA: CMS, the US Food and Drug Administration, and the Centers for Disease Control and Prevention. In addition, Dr MacConaill discussed the importance of simplifying consent and enrollment forms, recommending a 2-page basic form that patients would find easier to complete. I briefly discussed these issues with Dr MacConaill regarding the next steps in setting standards for tissue collection and supporting the need to simplify the consent and enrollment forms for patients. Both these conditions are vital to the advancement of genomic science and, without question, are important to the patient community. The last to speak was Richard Klausner, Sr, PhD, vice president and chief medical officer of Illumina. I was prepared to hear a brand pitch for the company’s products from him, but I was wrong! Instead, he shared his vision of a Global Initiative—quite

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Richard Klausner, Sr, PhD, vice president and chief medical officer of Illumina, with Peg Ford at the Illumina Discovery Symposium held in conjunction with the 2014 meeting of the American Association for Cancer Research.

a hopeful end to a most interesting day for an advocate. He spoke of his commitment to bring all stakeholders (pharma, industry, academia, Congress, physicians, healthcare providers, payers, and the patient community) to the table for the benefit of humankind by open and transparent collaboration, communication, and sharing all findings with equal access for everyone. Prior to joining Illumina in 2013, Rick (as he likes to be called) filled many roles, for instance, as executive director for Global Health at the Bill and Melinda Gates Foundation and as the eleventh director of the National Cancer Institute

Continued from page 13

between 1995 and 2001. Listening to his vision of the transformation of medicine through technology, and considering his enthusiasm and confidence as well as his impressive background, I was moved to expect that if anyone could be the bridge to conquer this challenge, it just might be Rick! It is an idea I feel the patient community desires and is hoping to see happen in which all aspects of medicine work harmoniously together, rather than with any form of competition, to benefit the individual as well as humankind. Perhaps we are on the cusp of a paradigm shift, and I personally applaud Rick’s passion and dedication to make this transformation happen in the not-too-distant future! I look forward with hope to observing his progress in this dynamic initiative! Yes, we certainly continue to face challenges, but as reported here, researchers are making bold steps into the new frontier of science and medicine. I see greater promise than ever before to finally move closer to achieving what President Richard Nixon declared as the “War on Cancer,” when he signed the National Cancer Act into law on December 23, 1971, stating, “I hope in the years ahead we will look back on this action today as the most significant action taken during my Administration.” l

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Conference News: AACR

Highlights From the American Association for Cancer Research Annual Meeting Alice Goodman

The American Association for Cancer Research (AACR) held its annual meeting in San Diego, California, April 5-9, 2014. Presentations at this meeting are typically focused on new research in therapeutics and epidemiology. Below are brief reports on some highlights from the meeting related to cancer risk and health-related behaviors.

Irregular Menses and Ovarian Cancer The first prospective study to link reproduction to ovarian cancer risk found that a history of irregular menstrual cycles at age 26 years predicted the eventual development of aggressive ovarian cancer. In fact, women with irregular menses had as high as a 2-fold increase in the risk of ovarian cancer and a more than 2-fold increase in the risk of ovarian cancer death. These findings are important, said lead author Barbara A. Cohn, PhD, MPH, of the Public Health Institute in Berkeley, California, because by the time most ovarian cancers are detected, they are already symptomatic and aggressive. “These data are the first solid lead we’ve had that has potential for earlier diagnosis. This is an opportunity to identify underlying mechanisms and ways to prevent the 90% of sporadic ovarian cancers that occur without known heritable risk,” she added. “The devil is in the details,” Cohn said. “We defined ‘irregular’ as cycles longer than 35 days or anovulatory menstrual cycles. In other words, these women could not predict when their menses was coming.”

Women with irregular cycles had a 37% increased risk of developing ovarian cancer and more than a 2-fold increase in ovarian cancer death due to more late-stage disease and more aggressive histology at diagnosis.

The study enrolled only pregnant women in order to rule out the effect of fertility drugs and infertility on the risk of developing ovarian cancer. As part of the Child Health and Development Studies, 14,403 pregnant women were recruited from 1959 to 1967. At baseline (median age, 26 years), women were asked to characterize their menstrual cycles. Thirteen percent reported irregular menses according to the definition Cohn described. These data were linked to California

Vital Statistics and National Death Index files to detect 103 cases of ovarian cancer, histology, stage, grade, and mortality (there were 65 deaths). Women with irregular cycles had a 37% increased risk of developing ovarian cancer and more than a 2-fold increase in ovarian cancer death due to more latestage disease and more aggressive histology at diagnosis. The risk was greatest for late-stage, high-grade, and serous tumors, Cohn said.

In the overall analysis, irregular menses was associated with a 2.3 times greater risk of ovarian cancer death (P = .01) and a 3 times greater risk of death from latestage serous ovarian cancer (P = .01). The risk of developing late-stage or high-grade serous ovarian cancer was also significantly increased among women with a history of irregular menses (P = .02 and P = .07, respectively). Although these findings are hypothesis generating, Cohn said that young women with irregular menses might consider taking birth control pills. “Birth control pills seem to be protective and regularize menstrual cycles. Of course, this decision should be made in consultation with a physician, and individual risk factors need to be considered as well,” Cohn noted. l

Reference

Cohn BA, Cirillo PM, Wang ET, et al. Irregular menstruation predicts increased risk of subsequent ovarian cancer death in a prospective cohort, The Child Health and Development Studies. Presented at: 2014 Annual Meeting of the American Association for Cancer Research; April 5-9, 2014; San Diego, CA. Abstract LB-277.

Jump-Starting Smoking Cessation for Cancer Patients To commemorate the 50th anniversary of the US Surgeon General’s report on the dangers of tobacco, the AACR published a policy statement on tobacco use by cancer patients to coincide with its 2014 annual meeting. Scientific evidence shows that tobacco use in cancer patients leads to poorer outcomes by compromising response to therapy,

Surveys of oncologists and other healthcare providers show that smoking cessation is rarely offered to patients, even though most agree that tobacco affects cancer outcomes and should be part of cancer care.

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increasing treatment-related toxicity, increasing the risk of recurrence and second primary tumors, and hastening earlier death. Yet a certain proportion of patients continues to smoke. The policy statement emphasizes the need to integrate evidence-based tobacco-dependence treatment into all healthcare delivery. At the present time, there is a scarcity of dedicated cessation treatment programs available at oncology practices. The statement emphasizes that the “5 A’s” program developed by the US Department of Health and Human Services is a proven method of increasing rates of successful quitting. This model relies on the following steps: ASK about tobacco use at every clinic visit; ADVISE to quit; ASSESS interest in quitting; ASSIST by providing counseling and pharmacotherapy; and ARRANGE follow-up. Although the “5 A’s” model lacks an evidence base for patients with cancer, following this model could be instrumental in helping cancer patients to quit smoking. Surveys of oncologists and other healthcare providers show that smoking cessation is rarely offered to patients, even though most agree that tobacco affects cancer outcomes and should be part of cancer care. In one survey of members of the International

Association for the Study of Lung Cancer, more than 90% of respondents said this was important, yet only 40% discussed medications or provided any type of cessation support. Many respondents indicated the perceived inability to get patients to quit using tobacco as well as patient resistance to intervention programs were the main barriers to offering cessation support. AACR made 2 recommendations: (1) Patients with cancer who use tobacco or who have quit within the past 30 days should be provided with evidence-based tobacco-cessation assistance, ideally within or associated with the oncology practice; and (2) Tobacco use should be comprehensively and repeatedly documented for all patients so that the confounding effects of tobacco on cancer treatment, disease progression, comorbid events, and survival can be evaluated in clinical trials and in all cancer settings. l Reference

Toll BA, Brandon TH, Gritz ER, et al; Writing Committee for the AACR Subcommittee on Tobacco and Cancer. Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement. Clin Cancer Res. 2013;19(8):1-8. http://www.aacr.org/Uploads/DocumentRepository/LegAffairs/Tobacco/ AACRStatement_TobaccoUseCancerPatients_2013_CCR.pdf. Accessed April 16, 2014.

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Conference News: AACR Continued from page 21

Coffee Intake May Reduce Risk of Hepatocellular Carcinoma Increased consumption of coffee was associated with reduced risk of developing hepatocellular carcinoma (HCC), the most common type of liver cancer.1 A significant dose response was observed, noted lead author V. Wendy Setiawan, PhD, of the USC Norris Comprehensive Cancer Center in Los Angeles, California. People who drank between 1 to 3 cups of coffee per day had a 29% reduced risk of HCC, while those who drank 4 or more cups per day had a 42% lower risk. The researchers did not look at the effect of consumption of decaffeinated coffee. “Previous studies showed that coffee lowers the risk of HCC, but these studies were conducted outside of the US. We wanted to examine whether coffee consumption was associated with risk of HCC in multiethnic US populations,” she said. The study was based on a prospective analysis of approximately 180,000 men and women, including 52,548 Japanese Americans, 45,641 Caucasians, 39,097 Latinos, 29,486 African Americans, and 13,118 Native Hawaiians. Data were col-

The relationship between coffee consumption and lower risk of hepatocellular cancer was independent of ethnicity, gender, body mass index, smoking status, alcohol intake, and diabetes status. lected on coffee consumption and other lifestyle factors, and people were followed for up to 18 years. HCC developed in 498 participants: 171 Japanese Americans, 67 Caucasians, 153 Latinos, 73 African Americans, and 34 Native Hawaiians. The relationship between coffee consumption and lower risk of HCC was independent of ethnicity, gender, body mass index, smoking status, alcohol intake, and diabetes status. Also, in a subset analysis of participants with available hepatitis B and hepatitis C serologic status, the association between coffee consumption and HCC was independent of hepatitis infections.

Setiawan and colleagues plan to study the association between coffee consumption and incidence and mortality with chronic liver diseases across multiethnic groups. A related study showed that increased coffee intake was also associated with reduced risk of melanoma.2 Participants who consumed 4 or more cups of coffee per day had a 20% reduction in the risk of melanoma compared with non-coffee drinkers. No association was observed for decaffeinated coffee. The study analyzed data from the large, prospective NIH-AARP Diet and Health Study. Coffee intake was assessed at base-

line with a food intake questionnaire. Among 447,357 non-Hispanic whites who were cancer-free at baseline, 2904 developed melanoma during 4,329,044 person-years of follow-up. Respondents were followed from baseline until the date of first skin cancer diagnosis, the date of death, the end of study follow-up, or moving out of a catchment area (whichever occurred first). The analysis was adjusted for multiple potential confounders for melanoma risk in relationship to level of coffee intake. Lead author Erikka Loftfield, MPH, of the National Cancer Institute, said that additional study of caffeine and other coffee constituents is warranted in the prevention of melanoma. l References

1. Setiawan VW, Wilkens LR, Hernandez BY, et al. Coffee intake reduces hepatocellular carcinoma risk: the Multiethnic Cohort. Presented at: 2014 Annual Meeting of the American Association for Cancer Research; April 5-9, 2014; San Diego, CA. Abstract LB-281. 2. Loftfield E, Mayne S, Shebl F, et al. Prospective study of coffee drinking and risk of melanoma in the United States. Presented at: 2014 Annual Meeting of the American Association for Cancer Research; April 5-9, 2014; San Diego, CA. Abstract LB-280.

Obesity Linked to Poor Outcome in Colorectal Cancer Yet another study points out the dangers of obesity, in this case the relationship of prediagnosis obesity to poor outcomes for people with colorectal cancer. In fact, the presence of prediagnosis obesity trumped high microsatellite instability (MSI), a tumor marker usually associated with better outcomes. “We know that increased body mass index [BMI] is associated with a variety of poor health outcomes, including poor prognosis in survivors of breast and endometrial cancers. One of the clearest associations is with colorectal cancers. The timing of obesity is important, because increased BMI measured before diagnosis is predictive. After diagnosis, BMI is no longer predictive because patients get sick and lose weight,” explained lead author Peter T. Campbell, PhD, director of the Tumor Repository in the Epidemiology Research Program at the American Cancer Society in Atlanta, Georgia. “This study, to my knowledge, is the first study with sufficient numbers to investigate how these independent risk factors work together to influence survival

after a colorectal cancer diagnosis. We found that a high prediagnosis BMI is associated with increased all-cause and colorectal cancer–specific mortality after diagnosis. We also found that high BMI overrides the survival advantage conferred by an MSI-high tumor,” he said. “The take-home message is that BMI is prognostic. At the highest level (BMI >40 kg/m2), colorectal cancer mortality was increased by 48%. This is another reason to maintain lower body weight,” Campbell stated. The study was based on 6763 patients with invasive colorectal cancer who enrolled in the Colon Cancer Family Registry from 1997 to 2008. BMI 2 years prior to diagnosis and at age 20 years and adult weight gain were calculated from self-reports of height and weight. Tumor MSI status was available for 4987 patients. Median follow-up was 5.3 years. For every 5 kg/m2 increase in BMI, there was a 10% increase in all-cause mortality. For patients with MSIhigh and MSI-stable/MSI-low tumors, every 5 kg/m2 increase in BMI increased all-cause mortality by 19%

and 8%, respectively. A similar pattern was observed for the association between increased BMI and colorectal cancer–specific mortality as well, with the risk of colorectal cancer– specific mortality increasing by 7% for every 5 kg/m2 increase in BMI. “This study is unique because we looked at the joint impact of BMI and MSI. Obesity removes the net benefit of high MSI,” Campbell emphasized. He and his colleagues are planning to look at the association between prediagnosis obesity and other tumor markers implicated in colorectal cancer survival. The ultimate goal is to investigate the association between obesity and somatic tumor mutations to determine how obesity may drive cancer, Campbell noted. l Reference

Campbell PT, Newton C, Newcomb PA, et al. Prospective study of body mass index and adult weight change with colorectal cancer survival, overall and by tumor microsatellite instability status. Presented at: 2014 Annual Meeting of the American Association for Cancer Research; April 5-9, 2014; San Diego, CA. Abstract LB-276.

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Who Will Be the ONE? The Oncology Nurse Excellence Award Winner

The Oncology Nurse-APN/PA 速 (TON) is pleased to announce the 2014 ONE (Oncology Nurse Excellence) Award. This annual award recognizes an oncology nurse for outstanding contribution to oncology nursing practice, patient care, or education in 2014. The 4 leading nominees will be profiled online and in the August issues of TON and the Journal of Oncology Navigation & Survivorship 速 (JONS ). Readers will have an opportunity to nominate an individual online through July 15, 2014, and the winner will be announced at the Fifth Annual Academy of Oncology Nurse & Patient Navigators (AONN+) Conference, September 18-21, 2014, in Orlando, Florida, and profiled in the December issues of TON and JONS. The winner will also receive a plaque recognizing their contribution to oncology nursing, as well as a donation made to the charity of their choice in their name.

Nominate a nurse at

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