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December 2009

connect

The official news magazine of the oncology nursing society

Half of Patients With Cancer Are Older Than 65

Do You Know How to Care for Older Adults? Page 6 Trastuzumab-Induced Cardiotoxicity Page 10

Bloodstream Infections Page 15

Implantable Cancer Monitoring Device Page 16

Diane G. Cope, PhD, ARNP-BC, AOCNP®

Turn to page 19 for oncology nursing job listings. ONLINE_DEC09_Connect copy.indd 1

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INSTANTPOLL

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Have You Communicated to a Legislator About a Cancer Issue? In response to October ONS Connect’s instant poll, “Have you communicated to a legislator about a cancer issue?” 95% indicated “yes” (N = 19). If you’ve wanted to contact your legislators about healthcare issues but don’t know where to start, visit the ONS Legislative Action Center at www.onslac.org. Here you’ll find information about what ONS has identified as health policy priorities. Enter your zip code to get contact information for the elected officials for your area. Sign your name to one of the template e-mails or draft your own with a personal note, then click send to have it delivered on your behalf. To respond to this month’s poll, “Have you treated a patient you felt was too old to receive oncology treatment?” visit www.ONSConnect. org. Results will be shared in an upcoming issue. ✱

95%

said yes

You Tell Us, Readers! Responses to the December You Tell Us question, “What unique techniques do you use to help geriatric patients with cancer receive treatment?” can be found online at www.ONSConnect.org. To reply to the next You Tell Us question, “How do you transition an adolescent to adult patient status during cancer treatment?” e-mail Managing Editor Elisa Becze at pubONSConnect@ons.org by January 1. Responses will be included in ONS Connect’s March 2010 “You Tell Us” department. Submissions should be approximately 125 words and may be edited for clarity and space. ✱

What Happens on the Third of Every Month? Find out why RE:Connect blogger Kari Wujcik has come to dread the third day of every month—the day when new residents start on her unit. She shares the story of how a new resident poorly managed one of Kari’s patients, who was having difficulty breathing. Read how she advocated for proper treatment for the patient, and share your own thoughts, comments, and stories at http://reconnect.typepad.com/reconnect/2009/11/ the-3rd-of-every-month.html. ✱ 2

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ONS Connect is published monthly as a benefit for members of the Oncology Nursing Society, 125 Enterprise Drive, Pittsburgh, PA 15275-1214 USA. Mission The mission of ONS Connect is to • Provide timely news and resources to oncology nurses that can be incorporated easily into daily practice. • Communicate ONS updates and news. • Reinforce ONS as an industry leader and an authority in the healthcare field.

Editor Debra M. Wujcik, RN, PhD, AOCN® E-mail: ONSConnectEditor@ons.org Contributing Editors Seth Eisenberg, RN, OCN® Robin M. Lally, PhD, RN, BA, AOCN®, CNS Deborah McBride, RN, MSN, CPON® Susan Pillet, RN, CPNP, CPON® Hanan Saca-Hazboun, RN, MSN Joseph D. Tariman, RN, MN, ARNP-BC, OCN® Erin Wyatt, MSN, RN, OCN®, CBCN ONS Communications Staff Leonard Mafrica, MBA, CAE, Publisher Anne Snively, BS, CAE, Director of Communications Elisa Becze, BA, ELS, Managing Editor and Staff Writer Carrie Smith, BA, Copy Editor and Staff Writer Jason Mosley, Graphic Designer ONS President Brenda Nevidjon, RN, MSN, FAAN ONS Chief Executive Officer Paula T. Rieger, RN, MSN, AOCN®, FAAN National Office Information Phone: 866-257-4ONS, +1-412-859-6100 Fax: 877-369-5497, +1-412-859-6163 E-mail: pubONSConnect@ons.org ONS Web site: www.ons.org ONS supports the principle of financial disclosure and has taken steps to ensure that all ONS editors, editorial board members, reviewers, and authors understand and comply with its policy. ONS also respects the privacy of its customers. Copies of the ONS Financial Disclosure Policy and ONS Privacy Policy are available upon request by contacting ONS at customer.service@ons.org or 125 Enterprise Drive, Pittsburgh, PA 15275-1214 USA, Attn: Customer Service. All advertising is subject to the approval of the editor and publisher. ONS Mission Statement The mission of the Oncology Nursing Society is to promote excellence in oncology nursing and quality cancer care. ONS Core Values Integrity • Innovation • Stewardship Advocacy • Excellence • Inclusiveness

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INSIDE

6 Do You Know How to Care for Older Adults? up front

Half of patients with cancer are older than 65. Two ONS members describe the special considerations nurses need to know when working with the geriatric population.

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Five-minute in-service

Learn to Assess for and Manage Trastuzumab-Induced Cardiotoxicity

Learn what nurses need to know when a patient develops this rare but serious complication.

15 Prevent Bloodstream Infections From Access Devices A CLOSER LOOK

Get nursing considerations and safety tips for preventing patient infections from venous access devices.

ALSO IN THIS ISSUE

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ONSCONNECT.ORG Get a preview of what’s in store this month online with ONS Connect.

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WEB CONNECT Find online resources for geriatric oncology.

5 EDITOR’S NOTE Oncology nurses are leaders in the transformation of geriatric oncology care.

13 JUST IN The latest news from the oncology field

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ONS GERIATRICS TASK FORCE Find out how ONS is becoming a leader in geriatrics.

17 WORKING FOR YOU

16 Implantable Device Monitors Cancer Treatment Effectiveness

ONS works to address gaps in geriatric oncology care.

Implanted devices provide continuous information about the in situ environment, which enables personalization of therapy and improved early detection of metastasis.

17 CALENDAR OF EVENTS

NEW Treatments, new hope

ONS programs and deadlines for winter

Check us out on the Web! Visit www.ONSConnect.org to view this month’s interactive digital edition.

ONS Connect is indexed in the Cumulative Index to Nursing and Allied Health Literature®, MEDLINE®, and the International Nursing Index. The Oncology Nursing Society and the ONS Connect Editorial Board do not assume responsibility for the opinions expressed by authors. Editorials represent the opinions of the authors and not necessarily those of the Oncology Nursing Society. Acceptance of advertising or corporate support does not indicate or imply endorsement by ONS Connect or the Oncology Nursing Society. Mention of specific products and opinions related to those products do not indicate or imply endorsement by ONS Connect or the Oncology Nursing Society. Web sites published in ONS Connect are provided for information only; the hosts are responsible for their own content and availability. Postage Privileges: Periodical rates paid at Pittsburgh, PA, and at additional mailing offices. Postmaster: Send address changes to ONS Connect, Oncology Nursing Society, 125 Enterprise Drive, Pittsburgh, PA 15275-1214 USA. Published monthly by the Oncology Nursing Society, P.O. Box 3510, Pittsburgh, PA 15230-3510 USA. Yearly subscription rates are $29.99 for individual nonmembers and $39.99 for institutions. As part of ONS membership dues, $4.53 are for a one-year subscription to ONS Connect. Vol. 24, No. 12. ISSN: 1935-1623. Copyright © 2009 by the Oncology Nursing Society. Blanket permission for copying any material in ONS Connect is granted to ONS members.

Printed on 10% postconsumer recycled paper. Please recycle this publication.

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ONSCONNECT.ORG

Don’t Miss These Great Articles at www.ONSConnect.org You Tell Us ONS Connect readers share the techniques they use to help geriatric patients with cancer receive treatment. Just In Find out how a new instrument may enable noninvasive detection of melanoma. Capitol Connection The future of nursing: RWJ Foundation and the Institute of Medicine launch a new initiative.

Caregiver Care Is religion such a taboo? How you can use your faith to support your interactions with patients. Staying on Top Find out how ONS’s Oncology Nursing Fingerprint can help newer nurses advance their practice. Question Mark What fall assessment tools are used by ONS members? ONS Foundation Read how an ONS Foundation educational scholarship enabled a nurse to earn her BSN.

ONS Election Your vote can make a difference.

WEBCONNECT

Go Online for Geriatric Oncology Resources [By Deborah Braccia, RN, DNSc, OCN ®, ONS Web Site Editor]

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ncreased age is one of the greatest risk factors for cancer. Seventy-seven percent of all cancers occur in individuals older than 55 (www.cancer.org/ downloads/STT/500809web.pdf). The following resources will assist with caring for this special population. • The ONS Web Site Geriatrics Clinical Resource Area (www.ons.org/Clin icalResources/SpecialPopulations/ Geriatrics) is your gateway to information on geriatrics. • The American Geriatrics Society (www. americangeriatrics.org) is devoted to improving the health, independence, and quality of life of all older people. • The American Society on Aging (www.asaging.org/index.cfm) is committed to enhancing the knowledge and skills of those who improve the

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quality of life of older adults and their families. • The Hartford Institute for Geriatric Nursing (www.hartfordign.org) disseminates best practices to nursing students, faculty, practicing nurses, and policy makers. • The Geriatric Oncology Consortium (www.thegoc.org) addresses agebased disparities in cancer research, education, and treatment through a national, community-based program. • The Gerontological Advanced Practice Nurses Association (www.gapna. org) provides continuing education in gerontologic care and peer support from experienced clinicians. • The Gerontological Nursing Inter­ ventions Research Center (www. nursing.uiowa.edu/excellence/nurs

ing_interventions) conducts intervention-focused research reDeborah Braccia, ­g a r d i n g t h e RN, DNSc, OCN® health of older adults in a variety of care settings. • The Gerontological Society of America ( w w w. g e r o n . o r g ) i s d e v o t e d t o research, education, and practice in the field of aging. • The National Gerontological Nurses Association (www.ngna.org) is dedicated to the clinical care of older adults across diverse care settings. • The National Institute on Aging (www. nia.nih.gov) leads scientific efforts to understand the nature of aging and to extend the healthy, active years of life. ✱

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EDITOR’SNOTE

Oncology Nurses Are Leaders in the Transformation of Geriatric Oncology Care [By Debra M. Wujcik, RN, PhD, AOCN®, Editor]

M Debra M. Wujcik, RN, PhD, AOCN ®, Editor

embership in a well-known organization for retired persons is available at age 50. However, the promotional material comes through the mail well before then, serving as an irritating reminder of our own aging. With 50 being the new 40 and many seniors working well past the traditional retirement age, determining when one moves from an adult to geriatric state is difficult. Chronologic and physiologic ages are not the same. As we age, our body functions decline. The physi-

As the population ages, lives longer, and has better health well into the seventh and eighth decades, oncology nurses will be presented with new challenges. ologic changes vary according to various reserves in the organs. Those who smoke, who are obese, or who have chronic health conditions may age more quickly and have significantly less reserve than others who are the same chronologic age. To care for older patients, nurses must understand the differences in normal aging and disease. For example, renal impairment may be a part of aging, but renal failure is not. Also urinary incontinence is not part of normal aging but may occur at any age and is frequently treatable. Older adults who develop cancer often have preexisting comorbidities that are being treated with multiple medications. Metabolism and excretion of

drugs may be slowed by declining renal and hepatic functioning. Complications such as dehydration may develop more quickly with chemotherapy-induced nausea and vomiting and may lead to further complications. Functional ability, independence, and quality-of-life issues are of greater concern in older adults because the return to pretreatment activities may be severely compromised. The ONS and Geriatric Oncology Consortium Joint Position on Cancer Care in the Older Adult (www.ons.org/ Publications/Positions/Geriatric) notes that compared with younger adults, those 65 years or older are less likely to be screened for cancer. Also, they are less likely to be offered curative therapy or participation in clinical trials once a cancer diagnosis is made. As the population ages, lives longer, and has better health well into the seventh and eighth decades, oncology nurses will be presented with new challenges. Contributing Editor Joseph Tariman, RN, MN, APRN-BC, OCN®, discusses ethical and quality-of-life issues along with the need for education in this emerging specialty in this month’s Up Front feature (see p. 6). A number of useful online resources for information on geriatric oncology are provided in Web Connect (see p. 4). Take a few moments to read this issue of ONS Connect and explore the online resources. Oncology nurses can once again lead the way in transforming geriatric oncology care to meet the needs of our aging population. ✱ December 2009

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Half of Patients With Cancer Are Older Than 65

Do You Know How to Care for Older Adults? Nancy Thompson, RN, MS, AOCNS速, says that the biggest challenge to overcome is a general apathy about geriatric oncology.

[By Joseph D. Tariman, RN, MN, APRN-BC, OCN速, Contributing Editor]

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s many oncology clinicians can attest, the number of older adults diagnosed with cancer is increasing. On a daily basis, inpatient and outpatient oncology data show that patients aged 65 years and older are now being treated with complex chemotherapeutic regimens for various types of cancer.

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According to the latest Surveillance, Epidemiology and End Results data, the incidence of new cancer cases is about 10 times greater for people 65 years and older, accounting for 54.7% of all newly diagnosed cancers (National Cancer Institute, 2009). Cancers of the prostate, breast, colon, pancreas, bladder, stomach, lung, and rectum are the most common cancers occurring in people older than 65. Moreover, despite a decrease in age-standardized death rates from all types of cancers, 568 more cancer deaths were reported in 2006 than in 2005 because of the growth and aging of the U.S. population (Jemal et al., 2009). A Need for Trained and Educated Oncology Nurses ONS member Nancy Thompson, RN, MS, AOCNS®, outpatient oncology clinical nurse specialist at Swedish Cancer Institute in Seattle, WA, observes that more than half of all cancers occur in people aged 65 or older. Thompson contends that with these kinds of statistics, the average oncology nurse should have a mailbox overflowing with nursing journals and newsletters full of geriatric-specific, evidence-based articles; oncology-focused geriatric nursing research findings; and other ongoing helpful tips and tools in working with the needs of this specific patient population. “[Geriatric care] is not merely providing care for an adult who is older; it requires specialized knowledge and skills,” Thompson says. “Yet, most oncology nurses do not view themselves as geriatric specialists and many could not even list the top five geriatric syndromes.” Highly trained, well-educated oncology nurses are clearly needed to deliver high-quality cancer care to older adults with cancer. ONS member Diane G. Cope, PhD, ARNP-BC, AOCNP®, oncology nurse

practitioner for Florida Cancer Specialists in Fort Myers, also agrees that with the increases in the U.S. older adult population, the risk of cancer with advancing age, and the number of older adult cancer survivors, oncology nurses should be competent in dealing with geriatric-specific health problems. Quality of Life for Geriatric Patients Quality-of-life research involving patients with cancer who are aged 65 or older has been limited with mixed results, Cope says. “Cancer diagnoses have been shown to be less associated with quality of life than other comorbid conditions, but a more recent study found significant negative association with quality of life and lung cancer or non-Hodgkin’s lymphoma,” Cope adds. Further research exploring the multitude of quality-of-life issues is critical for this unique older adult cancer patient population. Ethical Issues The major ethical issues in caring for older adults with cancer center around treatment decisions and financial resources, Cope says. “The decision to treat older adults with cancer is complex and must be evaluated on an individual basis with consideration of performance status, cancer stage, risks, benefits, and available social support. Older adults are often faced with limited incomes, and some cancer treatments are costly and require the identification of alternative financial support resources.” Thompson agrees. “The increasing cost of health care makes obtaining quality care more unreachable for many seniors on fixed incomes.” She notes that the most common ethical issues in clinical practice are decreasing dosages or choosing a less effective treatment based on the assumption that a patient can’t tolerate December 2009

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ONS Position Addresses Aging Population According to the American Cancer Society (2009), men and women aged 70 years or older have a lifetime probability of 37% and 26% for developing cancer, respectively. In 2007, ONS joined with the Geriatric Oncology Consortium (GOC) to develop a position statement related to the cancer care of older adults (www.ons.org/ Publications/Positions/Geriatric). The consortium identified that older adults with cancer are less likely to be offered aggressive treatment or to be included in cancer clinical trials. Evidence-based supportive care for older adults also tends to be underutilized. It is the position of ONS and GOC that older adults should have access to the full spectrum of cancer care, from screening to survivorship to end-of-life care, and that barriers to clinical trials be remedied. In addition, interdisciplinary teams and geriatric assessments should be used to provide optimal care to older adults with cancer. American Cancer Society. (2009). Probability of developing invasive cancer over selected age intervals, by sex, US, 2003–2005. Retrieved September 9, 2009, from http://www.cancer.org/ docroot/MED/content/downloads/ MED_1_1x_CFF2009_Probability_Dev_ Invasive_Cancer_Age_Inter.asp

Diane Cope, PhD, ARNP-BC, AOCNP®, says that future geriatric oncology care needs to emphasize clinical trials, comorbid conditions, and survivorship.

the more aggressive treatment because of age. Thompson says that she has observed other ethical issues as well. • Adult children who don’t want their parents with cancer treated aggressively because they want their inheritance • Geriatric patients eliminated from clinical trials because of subtle criteria that most older adults can’t meet, such as comorbidities • General oncologists not trained in geriatrics, resulting in a lack of geriatric assessments and substandard care • A general lack of research on such a large group of people (i.e., discrimination) Future Directions of Geriatric Oncology Care Thompson says she understands that the aging population will increase the need for oncology nurses to be educated in geriatric oncology and for more research to be done in this population.

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Recent improvements in targeted therapies and supportive care treatments have benefited older adult patients with cancer and will continue to do so. One of the biggest challenges that must be overcome is a general apathy about geriatric oncology. “It’s not viewed as being ‘sexy’ like new technologies, so nurses and researchers are not interested in the field,” Thompson admits. In addition, funding agencies don’t always see the value in the research so funding may be harder to obtain. The average oncology nurse doesn’t view it as a topic to be an expert in. Cope says that clinical trials and cancer practice guidelines for older adults have been limited in the past. “Gero-oncology care in the future will need to emphasize clinical trials, screening, diagnosis, and cancer treatment strategies; comorbidity conditions as they impact cancer care; and survivorship issues for older adults to ensure optimum quality of life,” Cope says.

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One of the pressing challenges in the specialty of geriatric oncology will be the educational preparation of nurses to adequately care for older adults with cancer across a cancer care trajectory that is complicated by concurrent

comorbidities, age-related organ functional changes, and limitations in psychosocial and socioeconomic factors. Geriatric oncology nursing research is critical to facilitate the development of evidence-based nursing practice

Program Supports Hospital Services for Older Patients Nurses Improving Care for Healthsystem Elders (NICHE) is a program through the Hartford Institute for Geriatric Nursing at New York University College of Nursing. Since 1992, the program has provided materials and services to stimulate and support the implementation of protocols and programs that benefit hospitalized older patients. Its mission is to change the culture of healthcare facilities so patient-centered care is available for older adults. For example, the Geriatric Institutional Assessment Profile is a reliable and valid tool for hospitals to assess their readiness to implement change in the care of older adults and to monitor progress once the changes are complete. The NICHE benchmarking service analyzes the data and produces a report for the hospital. For more information, visit www.nicheprogram.org.

that specifically addresses many of the unmet needs of the older adult with cancer, Cope concludes. ✱ Jemal, A., Siegel, R., Ward, E., Hao, Y., Xu, J., & Thun, M.J. (2009). Cancer statistics, 2009. CA: A Cancer Journal for Clinicians, 59(4), 225–249. National Cancer Institute. (2009). Age distribution (%) of incidence cases by site, 2002–2006: All races, both sexes. Retrieved August 16, 2009, from http://seer.cancer.gov/csr/1975_2006/results_merged/topic_age_dist.pdf

Contributing Editor Joseph D. Tariman, RN, MN, ARNP-BC, OCN®, is a certified nurse practitioner and an Achievement Rewards for College Scientists and Behavioral Nursing Health Systems fellow in the School of Nursing at the University of Washington in Seattle.

[One nurse’s Perspective]

Maintaining Quality of Life Is an Important Part of Geriatric Oncology Care Mary Kate Eanniello, RN, MSN, OCN®, is the nurse educator for the cancer program at Hartford Hospital in Connecticut.

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s an inpatient oncology nurse, I act as a role model for integrating care of older adults when providing oncologic care. I am passionate about maintaining quality of life for older adults with cancer. The patients I’ve cared for want to stay independent and not go to a nursing home. When assisting geriatric patients with quality of life, family involvement is important. Good nutrition and mobility are needed to maintain an active life. On our unit, we have an exercise program to help fight fatigue and get people mobile. Three days per week, someone from a local fitness center conducts a gentle stretching class. A physician’s order is needed, but there are no limits; patients who need oxygen, have chest tubes, or use wheelchairs are included. I am part of a hospital-based group of nurses that care about geriatrics. We implemented a global geriatric educa-

tion program to ensure that specific care for older adults is threaded through all care provided in the hospital. For example, in the neutropenia guidelines, a note is made that geriatric patients may not mount a fever response. Our hospital has become NICHE (Nurses Improving Care for Healthsystem Elders) certified. Each unit has a geriatric resource nurse, who has undergone an eight-hour training program with the goal of incorporating geriatric care throughout the unit. In addition, I am part of ONS’s task force to infuse geriatrics into ONS resources (see article on p. 14). My only limit is a lack of time, not a lack of enthusiasm or ideas. ✱ December 2009

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FIVEMINUTEINSERVICE As Seen in the Oncology Nursing Forum

Learn to Assess for and Manage Trastuzumab-Induced Cardiotoxicity [By Elisa Becze, BA, ELS, ONS Staff Writer]

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lthough today’s breast cancer treatments are more effective than ever, that efficacy can come with short- and long-term toxicities. Cardiotoxicity, although rare, can be a serious side effect of cancer treatments such as anthracyclines, taxanes, radiation, hormonal therapy, tyrosine kinase–targeting drugs, and trastuzumab. Trastuzumab can cause cardiotoxic effects—including left ventricular (LV) cardiac dysfunction, dysrhythmias, hypertension, cardiac failure, cardiomyopathy, and death—with reported incidence rates ranging from 2.6%–4.5% when the drug is used alone and as high as 27% when it is used in combination with anthracyclines. In their article in the November 2009 issue of the Oncology Nursing Forum, Moss, Starbuck, Mayer, Harwood, and Glotzer suggested that the actual incidence rates may be even higher, pointing out that the clinical trials the numbers are based on excluded women with a history of cardiac symptoms. Moss et al. explained monitoring and management strategies oncology nurses can use in patients exhibiting cardiac side effects from trastuzumab and described the patient education that nurses should provide. Trastuzumab and the Heart Because trastuzumab is an antibody to ErbB2, an epidermal growth factor, it can

also affect the heart. Cardiomyocyte survival and growth require ErbB2; blocking ErbB2’s pathway influences heart function and makes the heart more suscep-

tible to cardiotoxic stress. Trastuzumabinduced cardiotoxicity usually manifests as a decline in LV function, which often is reversible when the drug is discontinued.

Key Definitions Left ventricular dysfunction: Occurs when the left ventricle of the heart decreases in function, leading to congestive heart failure, myocardial infarction, or other cardiovascular diseases. The condition is diagnosed by measuring left ventricular ejection fraction through echocardiography or multigated acquisition scanning. Trastuzumab: A monoclonal antibody to ErbB2, a member of the growth factor family of tyrosine, that inhibits proliferation of tumor cells that overexpress HER2. Initially used for metastatic HER2-positive breast cancer, the drug is now approved for use in the adjuvant setting.

Five-Minute In-Service is a monthly feature that offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing or Oncology Nursing Forum (ONF). This edition summarizes “Trastuzumab-Induced Cardiotoxicity” by Lisa Stegall Moss, MSN, RN, OCN®, ANP-C, Mandy Fields Starbuck, MSN, RN, ANP-C, Deborah K. Mayer, PhD, RN, AOCN®, FAAN, Elaine Brooks Harwood, MSN, RN, APRN-BC, and Jana Glotzer, MSN, RN, ANP, which was featured in the November 2009 issue of ONF. Questions regarding the information presented in this Five-Minute In-Service should be directed to the ONF editor at ONFEditor@ons. org. Photocopying of this article for educational purposes and group discussion is permitted.

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Cardiac Risk Assessment and Monitoring Current cardiac monitoring recommendations are based on the use of trastuzumab in the metastatic setting. However, because the drug is now approved for adjuvant use as well, the authors suggest that more thorough monitoring is necessary because of better prognoses and higher life expectancies. The manufacturer recommends the following monitoring protocol for patients receiving trastuzumab. • Measure baseline LV ejection fraction (LVEF) prior to start of treatment. • Monitor LVEF every three months during treatment and following completion. • For two years after treatment, LVEF should be measured every six months. The assessment is usually done with echocardiography or multigated acquisition scanning. Normal LVEF is 55%– 70%. Oncology nurses should ensure that a patient’s history and physical assessment include risk factors for LV dysfunction (see Figure 1). Nurses also should assess for clinical signs and symptoms of heart failure at patient appointments, including dyspnea, increased cough, paroxysmal nocturnal dyspnea, peripheral edema, and S3 gallop. If a patient has three or more risk factors and the benefits of using trastuzumab are determined to outweigh the risks, LVEF should be monitored more frequently than every three months. For a prototype risk assessment tool, refer to the full article by Moss et al. (2009). The tool is currently being pilot tested for clinical practice and has been reviewed and verified by three medical oncologists, two nurse practitioners, and seven oncology nurses.

Treatment of Cardiotoxicity Patients who were taking beta blockers or statins prior to treatment with trastuzumab should continue those medications. Angiotensin-converting enzyme inhibitors and beta blockers are also indicated as standard treatment for trastuzumab cardiotoxicity because they have been shown to reduce decline in LV function and possibly reverse further damage. However, further cardiotoxicity despite the use of these drugs may require trastuzumab to be discontinued. Patient Education The authors contended that current patient education materials for trastuzumab may downplay the risk of cardiotoxicity from the drug. A review of those materials found that most listed cardiotoxicity as an uncommon or rare event; however, the materials did not indicate that women with preexisting heart conditions were omitted from clinical trials and that women in the studies were younger than average. Also, women who developed mild cardiac symptoms were not included in the final statistics. When educating patients about the side effects of trastuzumab, healthcare providers should be sure to explain the potential for cardiotoxicity as well as the signs and symptoms to watch for. They should emphasize that early detection of heart failure is important and to report those symptoms immediately. The authors also suggested that a recommended cardiac monitoring schedule be provided to patients at the start of treatment so they can be sure they are getting the testing they need at each appointment.

Figure 1. Evaluation for Left Ventricular Dysfunction Patient History • Myocardial infarction • Angina • Heart failure • Valvular disease • Pacemaker or intracardic device • Hypertension • Hyper lipidemia • Tobacco use • Diabetes • Family history of left ventricular dysfunction Physical Examination • Vital signs • Pulses • Bruits • Jugular venous distension • Lung and heart auscultation • Edema in extremities Other Assessment • Functional assessment • New York Heart Association classification status • Activities of daily living (e.g., dressing, showering, doing housework, walking, climbing stairs)

For more information on cardiotoxicity from trastuzumab, refer to the full article by Moss et al. (2009). ✱ Moss, L.S., Starbuck, M.F., Mayer, D.K., Harwood, E.B., & Glotzer, J. (2009). Trastuzumabinduced cardiotoxicity. Oncology Nursing Forum, 36(6), 676–685.

Free continuing nursing education credits are available by reading the full version of this article and completing an online test. To access the test for this and other articles, visit http://evaluationcenter.ons.org.

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Get latest and greatest education on today’s oncology hot topics Share ideas and experiences with your nursing peers

Take home practical information you’ll use in your daily practice

Expand your clinical skills

In av for ai m la at bl io ei nw ww n J il w. an l b on ua e s.o ry rg .

Learn about the newest treatments and therapies

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n s

JUSTIN

[By Deborah McBride, RN, MSN, CPON ®, Contributing Editor]

Protein That Inhibits Metastasis Is Discovered

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esearchers have found a protein that metastatic tumors don’t secrete. Metastasis is one of the leading causes of death from cancer. The researchers believe that tumors prepare places in distant organs for metastases by secreting certain proteins that encourage tumor growth. Nonmetastatic tumors secrete a protein called prosaposin, which inhibits metastasis by causing production of factors that block the growth of blood vessels. The researchers found that cells from localized prostate and breast tumors that didn’t metastasize secreted high levels of prosaposin whereas metastatic tumors secreted very little. When the researchers injected mice with tumor cells that were known to be highly metastatic but to which they had added prosaposin, lung metastases were reduced by 80%, lymph node metastases were completely eliminated, and survival time was significantly increased. In addition, when they suppressed prosaposin expression in tumor cells, they saw more metastases. When

prosaposin was directly injected into mice that had also received an injection of tumor cells, the tumor cells formed virtually no metastases in the lung, or if they did, formed much smaller colonies. These mice lived 30% longer than mice not receiving prosaposin. The researchers believe that prosaposin stimulates tumor suppressor p53 activity in the connective tissue surrounding the tumor. This, in turn, stimulates production of thrombospondin-1, a natural inhibitor of blood vessel growth, both in the tumor and in cells at distant locations. The researchers hope that drugs to prevent metastases or slow their growth can be used concurrently with treatments for primary tumors. Kang, S.Y., & Watnick, R.S. (2009). Regulation of tumor dormancy as a function of tumormediated paracrine regulation of stromal Tsp1 and VEGF expression. APMIS, 116(7–8), 638–647.

Social Isolation May Make Cancer Worse

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ccording to new research, social isolation can modify the biology of cancer and lead to different outcomes.

Female mice that were separated from their mothers had increased breast cancer growth compared to mice that were more content. Endocrine evaluation confirmed that isolated mice developed a heightened corticosterone stress response compared with group-housed mice. The study showed that an adverse social environment is associated with altered mammary gland gene expression and tumor growth. It has long been known that psychological factors influence disease, but this is one of the first studies to demonstrate how. The study adds to the work demonstrating that circulating stress hormones can influence the development of cancer by turning genes on and off in cells with the potential to become malignant. Previous work also has suggested that depression can have a negative effect on cancer prognosis. The researchers believe that with increased knowledge of the human genome, they can identify and dissect specific alterations that take place in cancer-prone tissues of individuals in at-risk environments that will help them understand and implement cancer prevention strategies. They caution that this work was carried out in mice and does not prove that stress causes cancer in humans. ✱ Williams, J.B., Pang, D., Delgado, B., Kocherginsky, M., Tretiakova, M., Krausz, T., et al. (2009). A model of gene-environment interaction reveals altered mammary gland gene expression and increased tumor growth following social isolation. Cancer Prevention Research, 2(10), 850–861.

Contributing Editor Deborah McBride, RN, MSN, CPON®, is a staff nurse III at the Kaiser Permanente Oakland Medical Center and an assistant professor at Samuel Merritt University in Oakland, CA. December 2009

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Task Force Helps Place ONS as a Leader in Geriatric Oncology

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eriatrics is an important part of oncology nursing practice because 77% of all cancer diagnoses occur in people aged 55 and older (www.cancer .org/downloads/STT/500809web.pdf). So concluded ONS’s Geriatrics Task Force, which convened in Pittsburgh in late 2008. ONS received funding from the Hartford Institute for Geriatric Nursing to develop the task force. The goals of the task force were to create an organization-wide dedication to the special needs of older adults with cancer and to continue to develop ONS’s position as a leader in this field. Developments over the past year included • Geriatric oncology was addressed at the Survivorship Task Force and the

Patient Navigation Task Force meetings, both of which are new strategic initiatives in ONS. • The ONS Institutes of Learning, Advanced Practice Nursing Conference, and Congress planning teams were asked to infuse geriatric oncology into the meetings. • A project team is developing a Trainthe-Trainer Geriatric Oncology Webbased program. • The ONS Publishing Team will review all ONS publications to include geriatric oncology perspectives, and the ONS periodicals editors will ensure that all authors give consideration to geriatric oncology perspectives in their articles. • The ONS Publishing Team and a work group are revising the Statement on

Nurse in Washington

Internship Grant Applications Application deadline: December 15 Program dates: March 14–16, 2010 Location: The Liaison Capitol Hill, Washington, DC Description: The Nurse in Washington Internship enables nurses to learn how to influence health care through the legislative and regulatory processes. For more information: Contact the ONS Health Policy Team at 866-257-4ONS or government.relations@ons.org.

the Scope and Standards of Oncology Practice and the Scope and Standards of Advanced Practice Nursing in Oncology Nursing to include geriatric oncology perspectives. Additionally, the Publishing Team is reviewing existing educational materials due for revision over the next three years to include geriatric perspectives. • The ONS Web site editor and editorial board are working to increase geriatric content on the Web site. • The ONS Publishing Team is exploring the possibility of developing ambulatory care guidelines for the care of older adults. Work will continue throughout the coming months on these and other task force recommendations. ✱

The Choice is Clear. Whether it's our cutting-edge technology, our innovative treatments or our compassionate, patient-focused care that brings you to work with us, one thing is clear, North Shore Medical Center is one of a kind. A multi-site, integrated healthcare system serving Boston's North Shore, we offer our employees unwavering support, deep respect and countless opportunities for career advancement. North Shore Medical Center is the place to build your career. Make the right choice.

Nurse Manager Medical Oncology Unit

Manage and lead a dynamic team on our fast-paced 40-bed medical oncology specialty unit in collaboration with the MGH/NSMC Cancer Center. Oversee day-to-day management, operations and budget; implement effective strategies, goals and standards; educate, evaluate and develop plans for professional growth with staff. Requires 5 yrs.’ progressively responsible management/leadership exp. with effective communication and interdisciplinary team building skills. Strong clinical knowledge of oncology required. BSN required, MSN or currently enrolled in an accredited program a plus. We offer you the benefits you would expect from a major affiliate of Partners Healthcare, plus a few you may not! Learn more and apply at: www.enjoywhereyouwork.com Or send resumes to: Regina Cullen, Lead Nurse Recruiter; rcullen@partners.org; 978-825-6283

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ACLOSERLOOK

Prevent Bloodstream Infections From Access Devices [By Seth Eisenberg, RN, OCN ®, Contributing Editor]

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atients with cancer often require venous access for treatment and supportive therapies, which can increase their susceptibility to infection. Peripheral and long-term central venous catheters (CVCs) can become infected via several routes. Bacterial colonization during insertion, particularly with a patient’s endogenous flora, is a significant source of infection. Gram-positive organisms such as coagulase-negative staph, gram-negative such as pseudomonas, and Candida can also be encountered. Recent changes to what the Centers for Medicare and Medicaid Services will reimburse for hospital-acquired infections have prompted medical facilities to further scrutinize how infections can be prevented. In addition, in July 2009 the Infectious Diseases Society of America (IDSA) published updated guidelines for catheter-related bloodstream infections (CR-BSI) (see Figure 1). A relatively new paradigm for CVCs includes using maximum sterile barrier precautions, which requires wearing a sterile gown and gloves and using a sterile drape. Emphasis is also being placed on proper skin antisepsis prior to CVC insertion. Betadine has been shown to be inferior to 2% chlorhexidine (CHG). To be effective, CHG requires the area to be scrubbed back and forth rather than using traditional concentric circles. Although CHG is more expensive, the costs are offset by a significant reduction in infection rates. Needleless connectors may be a cause of CR-BSI. Some studies have shown a higher rate of infection with mechanical luer-activated devices than with splitseptum devices. To counter this potential

problem, antimicrobial caps are being marketed. However, multicenter controlled trials have not yet been conducted, making evaluation of efficacy difficult. Contamination while accessing the hub or while changing a needleless connector is the most common cause of postinsertion CR-BSI. Scrupulous hand washing is paramount. The product used to disinfect a needleless valve is not as important as the amount of time spent scrubbing the connector. A quick three- to five-second wipe with alcohol is not effective for removing microorganisms. In comparing alcohol to CHG for disinfecting needleless devices, both are equally efficacious provided vigorous friction is used for at least 15 seconds. Research continues regarding use of antibiotic lock solutions for prophylaxis. Some have shown benefit over heparin or normal saline, but the results have been inconsistent. Several different brands of antimicrobial-impregnated venous catheters are on the market. Those containing a combination of CHG and silver sulfadiazine and those coated with minocycline/rifampicin have been shown to be beneficial. CHG is also being used in dressings, as an externally applied patch or impregnated into the dressing itself. Both of these products have demonstrated efficacy. Dedicated IV therapy teams also can have a significant impact in decreasing CR-BSI. For facilities where this is not an option, nursing education remains the cornerstone in preventing this potentially fatal complication. A bibliography for this article can be found at www.ONSConnect.org under “Connect Extras.” ✱

Figure 1. Summary of IDSA Guideline Recommendations Cultures • Blood samples should be obtained from the catheter and peripherally. • The catheter hub and skin should be cleaned with either alcohol, tincture of iodine, or 2% chlorhexidine (not povidone-iodine), allowing adequate time for drying. • The catheter tip (not subcutaneous portion) should be cultured. Management • Vancomycin is recommended for methicillin-resistant Staphylococcus aureus. Daptomycin is used for vancomycin minimum inhibitory concentration values > 2. • An echinocandin should be used for catheter-related candidema in patients who receive total parenteral nutrition, have a hematologic malignancy, or receive hematopoietic stem cell transplants. In general, these catheters should be removed. • Antibiotic locks should be used if there is no sign of tunnel or exitsite infection and the catheter is not being removed. • Locks should not be used for 48 hours and should be combined with systemic therapy. Mermel, L., Allon, M., Bouza, E., Craven, D., Flynn, P., O’Grady, N., Raad, I., et al. (2009). Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 49(1), 1–45.

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NEWTREATMENTSNEWHOPE

Implantable Device Monitors Treatment Effectiveness [By Deborah McBride, RN, MSN, CPON ®, Contributing Editor]

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eedle biopsies analyze tissue for cancer but are difficult to use to monitor ongoing cancer treatment because of their invasiveness. Researchers at the Massachusetts Institute of Technology have created a cancer monitoring prototype the size of a grain of rice. The device contains coated particles that bind with molecules linked to cancer, creating minuscule clumps that can be detected by noninvasive scans such as magnetic resonance imaging (MRI). The tiny devices are small enough to fit into the core of a biopsy needle and can be left at the site to monitor treatment. The investigators transplanted human tumors into mice and then used the implants to track levels of human chorionic gonadotropin, a hormone produced by the human tumor cells. The researchers successfully tracked the tumor marker in the mice for one month. The device, a cylindrical, 5 millimeter implant, is made of high-density polyethylene encased in a polycarbonate membrane with 10 nanometer-diameter pores. Magnetic

nanoparticles coated with antibodies specific to the target molecules are loaded into the device. Although changes currently can be monitored with MRI, the researchers are working on another version of the implantable device, made with a metal coil that acts as an antenna, that can be read with a hand-held detector. Biopsy is currently the gold standard for diagnosis, but the downside is that measurements can be recorded only at the time tissue is taken. In contrast, the implanted devices can continuously provide information about the in situ environment. The ability to repeatedly sample the local environment for tumor biomarkers, chemotherapeutic metastasis, and tumor metabolite concentrations could improve early detection of metastasis and personalize therapy. Short-term applications for this device include verification of successful tumor resection. According to the researchers, the device may hold possibilities not only for

sensing trouble but also remedying it by linking to a second device that would release a drug for treatment at the first sign of disease progression. The device could be set up to monitor different metabolic activity near a tumor and to measure pH and dissolved oxygen, which are indicators of responses to therapy. The researchers are planning to test the device on larger animals. They hope that the device will lead to a continuous stream of diagnostic information for weeks or months after a biopsy that will allow cancer to be treated as a chronic disease instead of an acute one. ✱ Daniel, K.D., Kim, G.Y., Vassiliou, C.C., Galindo, M., Guimaraes, A.R., Weissleder, R., et al. (2009). Implantable diagnostic device for cancer monitoring. Biosensors and Bioelectronics, 24(11), 3252–3257.

Contributing Editor Deborah McBride, RN, MSN, CPON®, is a staff nurse III at the Kaiser Permanente Oakland Medical Center and an assistant professor at Samuel Merritt University in Oakland, CA.

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This simple pocket guide provides patients with practical information about diagnosis, treatments, symptom management, and survivorship, as well as tools for keeping track of medications, contact information, side effects, and more.

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December 2009

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WORKINGFORYOU

ONS Works to Address Gaps in Geriatric Oncology Care [By Paula Rieger, RN, MSN, AOCN ®, FAAN, ONS Chief Executive Officer]

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dults aged 65 or older are the fastest-growing segment of the U.S. population. In 2008, 39 million people in the United States fell into this category. By 2050, that number is expected to double to more than 88 million individuals (U.S. Census Bureau, 2008). Because cancer incidence increases exponentially with advancing age, a surge in older patients with cancer is expected to challenge healthcare institutions and healthcare professionals. ONS has identified geriatric oncology as a thematic issue and will collaborate with other organizations to help advance our strategic goals. ONS has joined forces with the Hartford Institute for Geriatric Nursing and the College of Nursing at New York University, as well as 12 other

specialty nursing associations, in forming REASN (Resourcefully Enhancing Aging in Specialty Nursing) to create new and sustainable advanced geriatric training products and resources. These hospital-based associations represent more than 200,000 specialty nurses. ONS also is participating in the validation stage of a competency-development project, “Transitioning to Adult-Gerontology APRN Education: Ensuring the APRN Workforce Is Prepared to Care for Older Adults,” led by the American Association of Colleges of Nursing and the Hartford Institute for Geriatric Nursing. Together, we are building intensive collaborations to ensure geriatric competencies. In December 2008, ONS brought together a Geriatrics Task Force that

sparked efforts in a variety of areas, includ- Paula Rieger, ® ing the revision RN, MSN, AOCN , FAAN of our standards of oncology and advanced practice oncology nursing (see p. 14). Additionally, we joined with the other REASN members to endorse a global vision statement on the care of older adults. Other educational programs are planned for 2010 that will help educate oncology nurses in understanding the special considerations needed in caring for older adults with cancer. ✱ U.S. Census Bureau. (2008). An older and more diverse nation by midcentury. Retrieved November 13, 2009, from http://www.census.gov/ Press-Release/www/releases/archives/popula tion/012496.html

CALENDAROFEVENTS

Upcoming Oncology Nursing Events and Deadlines ONS Foundation Academic Scholarships Application deadline: February 1 Description: Bachelor’s, master’s and post-master’s certificate, and doctoral scholarships For more information or to apply: Visit www.nursingawards.org. 16th International Conference on Cancer Nursing Conference dates: March 7–10 Location: Atlanta, GA Description: Collaborate with nurs-

es from around the world to overcome the challenges and demands that cancer nurses face everywhere. For more information: Visit www. isncc.org.

ONS 35th Annual Congress Conference dates: May 13–15 Location: San Diego, CA For more information: Check www. ons.org in 2010.

Contact ONS 125 Enterprise Drive, Pittsburgh, PA 15275-1214 USA Phone: 866-257-4ONS (toll free, U.S. and Canada) or +1-412-859-6100 Fax: 877-369-5497 (toll free, U.S. and Canada) or +1-412-859-6165 E-mail: customer.service@ons.org • Web site: www.ons.org Oncology Calendar: http://onsopcontent.ons.org/Interactive/EventCalendar December 2009

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Submit Your Congress Abstract Today! Submit your abstract now for the ONS 35th Annual Congress, May 13–16, 2010, in San Diego, CA. Abstract presentations are focused in areas of administration/leadership development, clinical/ evidence-based practice, education, and research study. Selection of abstracts will be based solely on a blind peer review. Abstracts may be selected for presentation in podium sessions or presentation as a poster and published. Abstracts submitted must be of the author’s own completed work or work in progress and may or may not have been presented previously at the local or regional level. The primary authors must be RNs, licensed healthcare professionals, or doctorally prepared individuals. The primary authors must also consent to be the contact person. The scoring criteria for submitted abstracts is based on significance, background, a clearly defined purpose, measurable goals, clear presentation, and cutting-edge innovation.

Need help preparing an abstract? The idea of submitting an abstract for Congress can be intimidating and many questions about the process and structure may arise. Through the ONS Mentorship Program for Abstract Writers, novice abstract writers are partnered with experienced mentors to help guide you through the process. For more information, please contact ONS Education toll free at 866-257-4ONS or e-mail at education@ ons.org.

Don’t miss the deadline! Submission deadline is Tuesday, January 12. Please visit the abstract submission Web site at http://onsopcontent.ons.org/Meetings/Abstracts/abstractsubmission/default.asp to review the abstract submission instructions and to submit your abstract!

ONS Seeks Congress Abstract Reviewers Congress is just around the corner, and with it is the release of the latest cutting-edge and innovative abstracts. Abstracts submitted are focused in areas of administration/leadership development, clinical/evidencebased practice, education, and research study. As an abstract reviewer, ONS asks you to review abstracts and provide feedback within a very quick turnaround time period. You will provide feedback based on the abstract’s significance, problem and purpose, in-

terventions, interpretation, discussion, innovation, and general reviewer comments. Note: Reviewers with a PhD will be asked to review research study abstracts (abstract criteria are slightly different). If interested in reviewing abstracts, please send your name, e-mail address, and area of review interest to absquestions@ons.org by Thursday, December 17. Please respond to this call no later than Thursday, December 17, 2009.

For more information, contact, ONS Education toll free at 866-257-4ONS or e-mail absquestions@ons.org.

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CAREERCENTER Pacific Northwest, South Seattle Area Tacoma, Washington MultiCare Health System is searching for a full-time ARNP to work with our gynecologic oncologist providing pre- and postoperative care, rounding on patients in the hospital, and providing first assist in surgery. The MultiCare Regional Cancer Center is a network affiliate of the Seattle Cancer Care Alliance. The practice is conveniently located on the main campus of our 391-bed tertiary care center with a 43-bed dedicated inpatient oncology medical-surgical unit. Working just 30 miles south of Seattle on the shores of Puget Sound, you’ll experience the best of Northwest living, from big city amenities to the pristine beauty and recreational opportunities of the great outdoors. Excellent compensation, a full array of benefits, and a great location make for an exciting opportunity. Please visit our Web site to apply online at www.blazenewtrails.org, e-mail your curriculum vitae to blazenewtrails@multicare.org, or fax your curriculum vitae to 866-264-2818. Please refer to opportunity 5802 when responding. Tacoma, Washington—Palliative Medicine MultiCare Health System is searching for a full-time ARNP to work in our palliative medicine

program. Candidates should have a minimum of three years’ experience with at least two years’ experience in palliative medicine, hospice, or oncology. The practice is conveniently located on the main campus of our 391-bed tertiary care center with a 43-bed dedicated inpatient oncology medical-surgical unit. Working just 30 miles south of Seattle, on the shores of Puget Sound, you’ll experience the best of Northwest living, from big city amenities to the pristine beauty and recreational opportunities of the great outdoors. Excellent compensation, a full array of benefits, and a great location make for an exciting opportunity. Please visit our Web site to apply online at www.blazenewtrails.org, e-mail your curriculum vitae to blazenewtrails@ multicare.org, or fax your curriculum vitae to 866-264-2818. Please refer to opportunity #7292 when responding. MultiCare Health System is proud to be a drug-free workplace. Ambulatory Care Nurses Practice nursing in an environment that supports your professional growth and development. Memorial Sloan-Kettering Cancer Center ambulatory care nurses are an integral part of a unique practice model that contributes to our reputation for excellence in patient care. New and expanded

programs have created additional positions in New York City, Long Island, Westchester, and New Jersey in the following treatment areas. Office practices: In collaboration with designated attending physicians specializing in a specific disease, office practice nurses provide comprehensive professional nursing care to this defined patient population. A significant component of the role is care coordination across the continuum through office visits, telephone triage, and electronic communication. Treatment suites: Work collaboratively with designated physicians and in partnership with office practice nurses to provide patient education, assessment, and symptom management to a defined patient population. Treatment unit nurses administer standard chemotherapy regimens as well as cutting-edge treatment to patients on clinical trials. Both areas require a New York or New Jersey RN license and a minimum of one to two years of current related clinical experience. Chemotherapy certification is preferred for chemotherapy positions—or we will educate. We offer modified work schedules and an excellent compensation package, including tuition reimbursement. For consideration, please apply online at www.mskcc.org/jobs. EOE/AA

To view ONS’s online Career Center, visit http://careers.ons.org.

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December ONS Connect  

The December edition of ONS Connect, the Oncology Nursing Society's monthly news magazine