The official news magazine of the oncology nursing society
When Patients Canâ€™t Afford to Have Cancer Page 10
Nursing Safety for Oral Hazardous Drugs Page 8
How Long Is Too Long to Hospitalize Patients? Page 17 Jean Sellers, RN, MSN, OCNÂŽ
Turn to page 19 for oncology nursing job listings.
Practice What You Know: Validating Your Reimbursement Competency
You’ve completed the ONS reimbursement course, right? Now, confirm your competency in complicated oncology billing calculations and case scenarios by taking the test Practice What You Know: Validating Your Reimbursement Competency (www.ons.org/CourseDetail.aspx?course_id=30). This detailed test will confirm your reimbursement coding skills, offer additional practice, and help you gain confidence in this important skill. The Web-based competency test covers all of the critical skills required in oncology practice to help you demonstrate your proficiency in reimbursement and coding. It also offers more patient billing scenarios and calculations to further enhance your skills! At the completion of the test, you will be able to • Accurately identify chemotherapy versus therapeutic drugs • Accurately calculate billing units typically utilized in oncology practice • Accurately identify drug and administration codes. The Practice What You Know test is appropriate for anyone who has completed the Reimbursement for Nurses and Managers: The Keys to Successful Practice course (www.ons.org/CourseDetail.aspx?course_id=29), as well as for anyone who has experience with coding and would benefit from more practice or the desire to demonstrate competency in this skill. The competency test is modestly priced at $14.99 for ONS members. Or, check out the bundle (www.ons.org/CourseDetail.aspx?course_id=42) that includes both the course and the test for only $40. At these prices, you can’t afford not to participate. Just think, if you avoid just one billing error, that would more than pay the cost! Practice What You Know!
Take the test to confirm your skills.
Should You Tell the Staff That Is Caring for Your Family Member That You’re a Nurse? In response to November ONS Connect’s instant poll, “Should you tell the staff that is caring for your family member that you’re a nurse?” 64% indicated “yes” (N = 106). To respond to this month’s poll, “Have you ever felt compelled to give money directly to a patient for medication, meals, gas, etc.?” visit www.ONSConnect.org. Results will be shared in an upcoming issue. ✱
You Tell Us, Readers! Find out how nurses are raising funds to pay for patient needs not being met through insurance. Read the January You Tell Us responses online at www.ONSConnect.org. To reply to the next You Tell Us question, “How has membership in ONS’s special interest groups influenced your practice?” e-mail Managing Editor Elisa Becze at pubONSConnect@ons.org by February 1. Responses will be included in ONS Connect’s April 2010 “You Tell Us” department. Submissions should be approximately 125 words and may be edited for clarity and space. ✱
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® Marilyn L. Haas, PhD, RN, CNS, ANP-BC Deborah McBride, RN, MSN, CPON® Jennifer K. Mitchell, MSN, ANP-BC, GNP-BC Heather McCreery, RN, BS, OCN®, CCRC Susan Pillet, RN, CPNP, CPON® 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
New Breast Cancer Screening Guidelines Cause Division, Confusion, and Outrage RE:Connect blogger Joni Watson discusses the new breast cancer screening recommendations that were released by the U.S. Preventive Services Task Force in late November 2009. Get an overview of the guidelines, share what your patients are asking you, and discuss how this has changed your practice at http://reconnect.typepad.com/reconnect/2009/11/new-breast-cancer-screening-guidelines-cause-divisionconfusion-outrage.html. ✱
Candidate Change for the 2010 ONS Election Darcy Burbage, RN, MSN, AOCN®, CBCN, has voluntarily withdrawn her candidacy for the ONS director-at-large position. For a current list of candidates for the 2010 ONS Election, visit www.ons.org/Membership/ Election/Candidates. ✱ 4
10 When Patients Can’t Afford to Have Cancer UP FRONT
Continually, we hear about the financial and insurance crises and how they are affecting patients. Read how two ONS members are responding to patients’ financial needs at their workplaces.
ONSCONNECT.ORG Get a preview of what’s in store this month online with ONS Connect.
6 WEB CONNECT Find resources to help patients pay for cancer care.
14 Transdermal Medication Delivery Helps Prevent CINV
EDITOR’S NOTE Help patients save costs by managing medications.
Patients previously unable to use oral or parenteral antiemetics may find relief with transdermal CINV delivery systems.
8 NURSING SAFETY
ALSO IN THIS ISSUE
NEW Treatments, new hope
Daily Doses of Imatinib May Improve Survival for Children With High-Risk Leukemia A Children’s Oncology Group study has found that continuous exposure to imatinib for 2.5 years increases survival rates to 87% with no significant side effects.
17 Prolonged Hospitalization in Patients With Cancer: How Long Is Too Long? A CLOSER LOOK
Increased length of stay puts patients at higher risk for infections and is associated with higher healthcare costs.
Practice safe nursing with oral hazardous drugs.
CAPITOL CONNECTION ONS efforts to snuff out tobacco a success in 2009
9 JUST IN The latest news from the oncology field
18 WORKING FOR YOU ONS Board resolves to help Society thrive in 2010.
18 CALENDAR OF EVENTS ONS programs and deadlines for winter and spring
Check us out on the Web! Visit www.ONSConnect.org.
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. 25, No. 1. ISSN: 1935-1623. Copyright © 2010 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.
Don’t Miss These Great Articles at www.ONSConnect.org You Tell Us ONS Connect readers share how they are raising funds to pay for patient needs not being met through insurance.
Staying on Top Move up the ladder with the help of these ONS resources. Question Mark Can you tell me more about Cancer and Careers? Find out how ONS members can use this organization’s resources.
Caregiver Care It’s never too early—or too late—to plan for retirement. Get tips on managing your retirement accounts from the secretary of the ONS Foundation Board of Directors, a certified financial planner.
ONS 10x10 Campaign Learn how you can get involved in helping ONS achieve its goal of 40,000 members in 2010.
ONS Election Be a force in ONS by casting your vote in the ONS annual elections. Read how you may be able to help your chapter win an award for the highest voting percentage.
ONS Board Briefs The ONS Board approves a balanced budget for 2010; get additional highlights from the October and December Board meetings.
Find Resources to Help Patients Pay for Cancer Care [By Deborah Braccia, RN, DNSc, MPA, OCN ®, ONS Web Site Editor]
he cost of cancer treatment is a concern for many patients and their families. Even patients with insurance may face difficulty with treatment costs. In a national survey of patients with cancer and their families, 25% depleted all or most of their savings on cancer care, 33% reported problems paying cancer bills, and 27% of those insured delayed or did not obtain cancer care because of costs (USA Today, Kaiser Family Foundation, & Harvard School of Public Health, 2006). The following resources can help patients navigate and obtain assistance with the cost of cancer care. 6
• American Cancer Society: Health Insurance and Financial Assistance for the Cancer Patient (www.cancer. org/docroot/MIT/content/MIT_3_2X_ Medical_Insurance_and_Financial_ Assistance_for_the_Cancer_Patient. asp?%3e) • American Society of Clinical Oncology: Managing the Cost of Cancer Care (www.cancer.net/patient/ All+About+Cancer/Managing+the+C ost+of+Cancer+Care) • Cancer Financial Assistance Coalition (www.cancerfac.org) • National Cancer Institute: Financial Assistance and Other Resources for
People With Cancer (www.cancer. gov/cancertopics/factsheet/Support/ financial-resources) • National Coalition for Cancer Survivorship (www.canceradvocacy.org/ resources/financial.html) In addition to the resources listed, most pharmaceutical companies have patient assistance programs, so be sure to check out manufacturers’ Web sites for financial assistance with specific drugs. ✱ USA Today, Kaiser Family Foundation, & Harvard School of Public Health. (2006). Toplines: National survey of households affected by cancer. Retrieved November 10, 2009, from http:// www.kff.org/kaiserpolls/upload/7590.pdf
Oncology Nurses Can Help Patients Save Costs by Managing Their Medications [By Debra M. Wujcik, RN, PhD, AOCN®, Editor]
H Debra M. Wujcik, RN, PhD, AOCN ®, Editor
ow many times have you admitted patients to your unit or conducted an assessment of patients in your clinic or physician’s office and reviewed their current medications? You ask patients and caregivers to bring all of their current medications with them, and you ensure that the medical record matches those bottles. This verification of medications is a standard nursing practice. But do you also really look at the list to ensure that the patients still need every medication? Do you consider the
These small steps, done consistently one patient at a time, can improve response and decrease costs. potential interactions of the medications? And do you ask patients how they are tolerating the medications? I recently was with a friend and her husband during an emergency room admission, transfer to and discharge from a nursing home, and readmission to and discharge from the hospital. My friend, who has several chronic conditions, was experiencing severe side effects of chemotherapy. With each admission and discharge, more prescriptions were added. None of the physicians involved were comfortable with changing medications ordered by another specialist. After my friend’s last discharge, I set up the medications in a pill box for easier administration by family mem-
bers and was amazed that the number of pills to be taken per day was 25. The drawer of prescription bottles from the past six months of treatments contained more than 40 bottles. It was not surprising that my friend’s appetite was completely obstructed by the sheer number of pills and capsules to be consumed. Her husband was overwhelmed with the number of bottles and refills to keep track of. We face continued health insurance constraints and an economy that has not yet recovered. Nurses can help each patient manage their prescriptions to increase efficacy of medications and decrease costs caused by unnecessary prescriptions. It takes extra time to write a prescription for a small amount of a new medication, follow up with a telephone call to assess response, and then provide a full prescription for an effective medication. It also takes extra time to consider potential interactions and assess tolerance. But these small steps, done consistently one patient at a time, can improve response and decrease costs. My friend is a nurse who has the ability to sort out her medications for herself. Her appetite improved, and she feels much better. However, most of our patients do not have the knowledge needed to manage complicated medication regimens. As you read the issues in our feature article regarding dealing with the rising costs of cancer care, remember that medication management is one area where you can advocate for your patients on a daily basis. ✱ January 2010
Practice Safe Nursing With Oral Hazardous Drugs [By Seth Eisenberg, RN, BSN, Contributing Editor]
he number of currently available hazardous oral drugs is increasing and now includes small molecules and hormones in addition to traditional agents such as cyclophosphamide. (For a full list of oral hazardous drugs, visit www.ONSConnect.org.) Nurses are presented with unique safety challenges in handling these medications. General guidelines should be followed for handling hazardous oral drugs. • Use double gloves. • Wear a face shield if there is a potential for spraying, aerosolization, or splashing. • Crushing or manipulating should be done in a biologic safety cabinet.
• Wash hands thoroughly with soap and water after removing gloves. • Spoons, oral syringes, disposable medicine cups, or other equipment used to administer the agents must be discarded as hazardous waste. Some medications cannot be crushed, often because of timed-release or enteric coatings. When crushing hazardous oral drugs is necessary for use in nasogastric or gastric tubes or to mix with food, nurses may be at extremely high risk for exposure. A recommended method for dissolving and administering a capsule by syringe is to remove the plunger from the oral syringe and place the capsule
inside. Replace the plunger, draw warm fluid into the syringe, and allow the capsule to dissolve. The suspension can be administrated orally or via feeding tube. The Institute for Safe Medical Practices emphasizes the use of specialized oral syringes (not standard slip tip or luer-lock syringes) for administering oral hazardous drugs to prevent inadvertent IV administration. For more information, visit www.ismp.org/Newsletters/acutecare/articles/20091022.asp. Do you have a nursing safety issue you’d like to see addressed in this column? Send an e-mail to pubONSConnect@ons.org . ✱
ONS Efforts to Snuff Out Tobacco Were a Success in 2009 [By Leslie Greenberg, RN, MSN, OCN ®, ONS Health Policy Manager]
n 2009, the United States witnessed a transformation on how tobacco is handled in this country. On February 4 last year, President Obama signed into law the State Children’s Health Insurance Program (SCHIP). This legislation expanded healthcare coverage to millions of children, and it also increased the federal cigarette tax by 61 cents a pack. Then, on June 22, President Obama signed the Family Prevention and Tobacco Control Act (S. 982) into law. This legislation gives the U.S. Food and Drug Administration authority to regulate the production, sale, distribution, and marketing of all tobacco prod-
ucts, with emphasis on how tobacco is marketed toward children, including banning flavored cigarettes. ONS is actively involved in the implementation of this legislation. In September, we sent comments to the FDA (www.ons.org/LAC/HealthPolicy/media/ ons/docs/LAC/pdf/correspondence/111/ Regulation-of-Tobacco-Products.pdf) speaking to priorities for oncology nurses and sharing our position on Nursing Leadership in Global and Domestic Tobacco Control (www.ons.org/Publications/Positions/Tobacco). Also, ONS helped support others in the public health community in op-
posing a lawsuit by the tobacco industry. In November, a federal judge rejected an effort by tobacco companies to block provisions in the Family Prevention and Tobacco Control Act (www.tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=1179). However, work still needs to be done. A recent study from the Centers for Disease Control and Prevention showed that tobacco use in the United States has stopped declining (www.cdc.gov/ mmwr/preview/mmwrhtml/mm5844a2. htm). Thank you for your advocacy in 2009 and your continued partnership in 2010 and beyond. ✱
[By Deborah McBride, RN, MSN, CPON ®, Contributing Editor]
Marital Separation May Affect Cancer Survival
lthough married people are more likely to survive cancer, those who are separated at the time of diagnosis do not live as long as widowed, divorced, or never-married patients. Researchers said that their results suggest that the stress associated with marital separation may compromise an
cancer that develops in the body’s soft tissues. RMS is the most common type of sarcoma in children. Although progress has been made in its treatment, less than 30% of children whose cancer has metastasized survive more than five years. The gene produces a substance called fibroblast growth factor receptor 4 (FGFR4). Researchers examined FGFR4 gene expression in RMS tumors and
People who were married had a 63% chance of surviving five years, compared to 45% for people who were separated. individual’s immune system and contribute to susceptibility to cancer. The researchers analyzed data on 3.8 million people diagnosed with cancer from 1973–2004. They found that people who were married had a 63% chance of surviving five years, compared to 45% for people who were separated. The researchers looked at 5- and 10-year survival rates for married, widowed, divorced, and never-married patients as well as those going through a separation at the time of diagnosis. After married patients, never-married patients had the best outcomes, followed by those who had been divorced and then those who were widowed. Sprehn, G.C., Chambers, J.E., Saykin, A.J., Konski, A., & Johnstone, P.A. (2009). Decreased cancer survival in individuals separated at time of diagnosis: Critical period for cancer pathophysiology? Cancer, 115(21), 5108–5116.
Aggressive Childhood Cancer Linked to Mutations
found that high levels of gene expression were associated with advanced disease, including metastasis, as well as poor patient outcomes. They then used genetic manipulation to block expression of the FGFR4 gene in human RMS cells. Suppression of FGFR4 gene expression slowed the growth of the cells in laboratory experiments. In addition, when the cells were transplanted into mice, they grew more slowly and were less likely to spread to the lungs than cells with unsuppressed FGFR4 genes. According to the researchers, these findings are the first to show that when FGFR4 is overactive, it plays a key role in the growth and spread of RMS and that the gene could be an important target for therapy in the future. Vi, J.G., Cheuk, A.T., Tsang, P.S., Chung, J.Y., Song, Y.K., Desai, K., et al. (2009). Identification of FGFR4-activating mutations in human rhabdomyosarcomas that promote metastasis in xenotransplanted models. Journal of Clinical Investigation, 119(11), 3395–3407.
Liver Cancer Marker esearchers have found a gene that May Predict Prognosis
may be a new target for the treatment of rhabdomyosarcoma (RMS), a
small RNA molecule called miR26 shows promise in predicting
survival and response to adjuvant interferon treatment in patients with hepatocellular carcinoma, according to a new study. The molecule is one of one of approximately 1,000 microRNAs in the human genome that are believed to regulate the activity of several hundred genes. The researchers analyzed three independent patient cohorts in which individuals had undergone radical tumor resection for hepatocellular carcinoma. Cohort 1 consisted of 241 patients for whom microRNA microarray data were available. Cohorts 2 and 3 consisted of 214 patients drawn from prospective randomized, controlled trials of adjuvant therapy with interferon alfa. The researchers found that patients whose tumors had low miR-26 expression had poorer survival but were more likely to respond to adjuvant treatment with interferon alfa than patients whose tumors had high miR-26 expression. Overall, patients with low levels of miR-26 did not live as long as patients with higher levels. The difference in survival was about four years. Although low levels of miR-26 were linked to poor prognosis, those patients were more likely to benefit from interferon as an adjuvant therapy. This group survived at least 7.7 years longer than patients with low levels of miR-26 who did not receive interferon therapy. ✱ Ji, J., Shi, J., Budhu, A., Yu, Z., Forgues, M., Roessler, S., et al. (2009). MicroRNA expression, survival, and response to interferon in liver cancer. New England Journal of Medicine, 361(15), 1437–1447.
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. January 2010
When Patients Can’t Afford to Have Cancer Oncology Nurses Help Remove Financial Barriers to Cancer Care [By Susan Pillet, RN, CPNP, CPON®, Contributing Editor]
he headlines are ominous. The unemployment rate is climbing, standing at 10% in November 2009, up from 6.8% a year ago (Bureau of Labor Statistics, 2009). Companies, unsure of the economic recovery, are not hiring new workers. For every 1% increase in the unemployment rate, 1.1 million people lose their health insurance. Forty-six million adults younger than age 65 in the United States lack health insurance (Kaiser Family Foundation, 2008). In January 2009, the New York Times reported that states are seeing a 5%–10% increase in the Medicaid population (Sack & Zezima).
Jean Sellers, RN, MSN, OCN®, says that the financial stress patients experience may be worse than the stress from their cancer diagnosis. Helping Patients Cope Financially The stressors are adding up for patients with cancer. How do nurses help patients and families cope? “Often times, the financial catastrophe families experience is worse than the cancer diagnosis,” says ONS member Jean Sellers, RN, MSN, OCN®. She gives the example of a woman whose husband was in the operating room undergoing a craniotomy for removal of a brain tumor. The woman had put off her own treatment for a brain tumor, but what she really needed right then was $50 to have food at home for her family during her husband’s hospitalization. Sellers is the administrative director of the University of North Carolina
Cancer Outreach Program in Chapel Hill and is establishing nurse navigators throughout her state. The program is funded by the state legislature and is currently starting in Dare County, a rural area in eastern North Carolina. “I am based in Chapel Hill, but our commitment is to all the people of North Carolina. We have a number of leaders at our institution and in the state legislature who are committed to the success of this program,” Sellers says. “We identify barriers to care and use local resources to ensure that patients get needed treatments and provide education to others about the importance of preventive care.” ONS member Lynley Fow, ARNP, AOCNP®, is an advanced oncology cer-
tified nurse practitioner who works in private practice in Kirkland, WA. She finds that patients without insurance may delay treatment because they fear they can’t afford it. She says that an advantage of private practice is that it does give physicians the ability to write off copays or payment for a visit. “10%–15% of our patients have no insurance or poor insurance,” Fow says. It is unusual, though, for them to see patients lose their insurance during treatment. Fow identifies infusion nurses as being on the front line for financial crisis. Patients spend longer times in an infusion suite and will often first share their financial concerns with the nurses there. Patients may be hesitant to tell the January 2010
Lynley Fow, ARNP, AOCNP®, says that some patients without insurance may delay needed treatments for fear they can’t afford them.
Where to Send Your Patients for Financial Aid Are you struggling to find sources of financial aid for your patients? Most pharmaceutical companies offer patient assistance programs to income eligible patients and provide medications free or at a reduced cost. Check the product’s or manufacturer’s Web site to see if an assistance program is available for a particular prescription. In addition, several national organizations offer financial aid for copays or practical financial needs such as child care. CancerCare (www.cancercare.org), the Leukemia and Lymphoma Society (www.lls.org), and the Patient Advocate Foundation’s Copay Relief Program (www.patientadvocate.org, www.copays.org) are all possible sources of aid for your patients. Patients usually must meet certain guidelines pertaining to household income and cancer diagnosis. medical team for fear of not receiving adequate treatment because of a lack of insurance. Infusion nurses can reassure patients that they will be provided with standard of care therapy and not denied because of lack of insurance. “The only difference for patients without insurance is that their treatment takes place at the hospital rather 12
than the office. We don’t turn anyone away,” Fow says. She says that her practice works as a team to care for patients. Social workers help patients apply for charity care or Medicaid. A financial counselor reviews copays and informs patients what the maximum out-of-pocket expense will be. “We share with patients the cost of their
chemotherapy so they are not shocked when they get the bill,” Fow says. Her patients can also request a financial consult to look at their family’s budget to see if any expenses can be trimmed to help offset pharmacy copays, transportation for clinic visits, and over-the-counter medications. The pharmacy staff at Fow’s clinic help patients complete applications for patient assistance programs and advise them on using less expensive drugs to achieve the same results. Sellers says that similar services are available in North Carolina. Patients expressing the need for financial support must show their tax return. Their budgets also are assessed to see if any items can be trimmed. In addition, social workers in Sellers’ program can give patients $25 gas cards. The employees hold bake sales to fund this service. Programs That Offer Financial Aid So, what can oncology nurses do to help their patients with financial concerns? “We look for local resources to help patients in crisis,” Sellers says. “We’ve partnered with the health department, Salvation Army, and local hospitals and churches. For example, we had a patient whose car needed new brakes for her to have transportation for treatment appointments. We were able to find an organization in the local community to pay for the brake repair.” Fow’s workplace has a foundation that was established to provide patients with financial assistance. “The monies have come from fundraisers and patient bequests. We also use www.needymeds .org to find medication assistance for patients,” Fow says. She also advises patients about the $4 prescriptions offered at various local pharmacies. Sellers recommends the Patient Advocate Foundation (www.patientadvocate.org), a nonprofit organization
that provides a link for patients between their insurance company, employer, and/or creditors. The American Cancer Society offers a Road to Recovery program that can help with transportation. She also finds that local communities have much to give. Establishing relationships and building trust with local groups are critical to helping patients find assistance close to home. “We’ve developed a community care team called Hands of Hope,” Sellers says. “This is a volunteer program that helps community members learn about cancer and how they can support patients and families facing this diagnosis. The program collaborates with existing community programs so services are not duplicated. Most impor-
tant, it’s about teaching volunteers the difference they can make in the life of a patient and family on the cancer journey by simply understanding what may be their needs.” Program volunteers learn effective communication, the art of listening, and information about cancer, cancer prevention, and patient advocacy. Sellers says the goal is to have similar programs available throughout the state of North Carolina. “Recently we were invited to develop a mini volunteer orientation program for local high school students,” Sellers adds. “This is exciting because we will have the opportunity to provide students with skills that will follow them throughout their lives.” ✱
Bureau of Labor Statistics. (2009). Labor force statistics from the current population survey. Retrieved December 14, 2009, from http://data.bls.gov/PDQ/servlet/ SurveyOutputServlet?data_tool=latest_ numbers&series_id=LNS14000000 Kaiser Family Foundation. (2008). Medicaid, SCHIP and economic downturn: Policy challenges and policy responses. Retrieved October 30, 2009, from http://www.kff.org/medicaid/upload/7770ES.pdf Sack, K., & Zezima, K. (2009, January 21). Growing need for Medicaid strains states. New York Times. Retrieved October 30, 2009, from http:// www.nytimes.com/2009/01/22/us/22medicaid. html
Contributing Editor Susan Pillet, RN, CPNP, CPON®, is an advanced practice nurse for the Cancer Institute of New Jersey in New Brunswick.
[One nurse’s Perspective]
How Have Nurses Come Together to Help Patients in Need?
Alaskan Nurses Raise $110,000 Through Snow Machine Fundraiser Kathy Lopeman, RN, OCN®, is the oncology/infusion charge nurse at Central Peninsula Hospital in Soldotna, AK.
personal experience with cancer inspired me to improve care for patients with cancer. My mom died from colon cancer, and as a medical/surgical nurse, I could see where change was needed for people being treated. After much hard work, lots of studying, and oncology training, I was able to establish the unit where I now work. To support our patients in need, we have created a unique fundraiser: our annual Way Out Women snow machine ride. The 2010 ride will be our sixth. To add to the festivities, we always have team themes, complete with costumes. Participants obtain monetary donations from friends, family, coworkers, and community members. The last Saturday in February, the costumes are donned, the snow machines are fueled up, and we rev up the engines for a 50-mile ride in the beautiful Caribou Hills. After the ride is complete, we tally up the donations collected, vote on costumes, and have a great lunch. But the fun isn’t over yet! We then award prizes for the largest amount of donations collected and the best costumes. In addition, a silent auction starts the night before at the
meet and greet, which is completed on Saturday evening. Last year, we started a new event: the Wild and Wooly Bra contest. Bras are made by participants and then auctioned off. It was a great success and raised more than $600. We are proud that during the past five years, we have raised more than $110,000 through these charity events. The money is distributed to patients in need in the form of $1,000 grants. We have assisted folks from ages 8–80 and helped with practical things such as food, transportation, lodging, utilities, and more. All of the donations made are tax deductible through our health foundation. All of our prizes are donated and we have no administrative costs, so all of the proceeds benefit the patients. We’ve found that this is a great opportunity to combine our love of snow machines and help out our community. I would challenge all nurses to join our event. ✱ January 2010
FIVEMINUTEINSERVICE As Seen in the Clinical Journal of Oncology Nursing
Transdermal Medication Delivery Helps Prevent CINV [By Elisa Becze, BA, ELS, ONS Staff Writer]
Key Definitions Granisetron: a serotonin subtype 3 (5-HT3) receptor antagonist indicated to prevent nausea and vomiting from moderate to highly emetogenic chemotherapy; can be administered orally, intravenously, or via a new transdermal patch Transdermal medication delivery: provides systemic therapy by passive diffusion of medication through the skin
lthough antiemetics can be effective in preventing nausea and vomiting from moderate to highly emotogenic chemotherapy, some patients are unable to use the drugs because of route of administration. Parenteral antiemetics require an IV device and a healthcare professional or specially trained caregiver to administer. Oral antiemetics require patients to have a functioning gastrointestinal system, to adhere to an administration schedule, and to be able to swallow and retain the drug. Transdermal antiemetic delivery offers a new alternative for patients previously unable to take or tolerate parenteral or oral antiemetics. This type of delivery system administers medication continuously through the skin, bypassing the gastrointestinal system altogether and ensuring a constant rate of administration and prolonged action. Few side effects and risks exist, and administration requires no specialized nursing care. Granisetron transdermal system (Sancuso ®) is the first transdermal medication indicated for use in chemotherapy-induced nausea and vomiting. In her article in the December 2009 issue of the Clinical Journal of Oncology Nursing, Schulmeister describes the nursing and patient considerations for use of transdermal delivery of granisetron.
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 (CJON) or Oncology Nursing Forum. This edition summarizes “Granisetron Transdermal System: A New Option to Help Prevent Chemotherapy-Induced Nausea and Vomiting” by Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN, which was featured in the December 2009 issue of CJON. Questions regarding the information presented in this Five-Minute In-Service should be directed to the CJON editor at CJONEditor@ons.org. Photocopying of this article for educational purposes and group discussion is permitted.
Transdermal Delivery Systems The first transdermal medication delivery system, a skin patch that administered scopolamine for motion sickness, was introduced in 1981. However, transdermal systems were not in mainstream use until the nicotine patch was approved in 1996. Since then, transdermal delivery systems have been developed and approved for several medications, including clonidine, estradiol, fentanyl, lidocaine, and testosterone. Granisetron was approved for transdermal delivery in 2008. Benefits of transdermal delivery include • Long periods of continuous medication delivery to distant sites of action • Avoidance of first-pass metabolism • Ability of medication to directly enter the circulatory system • Minimal adverse effects (effects have been consistent with those seen with other delivery systems). Currently, two types of transdermal patches exist: reservoir-type and matrixtype. Both types contain a protective outer seal, a medication compartment, and a release liner. For reservoir patches (sometimes called a “ravioli”), the three components are separate layers. A medication reservoir is contained between the protective backing membrane and the rate-controlling microporous membrane. For matrix patches, all three components are contained in one layer, allowing for a smaller, thinner patch. In both designs, the rate of administration is controlled by the microporous release membrane. The rate of release is not affected by skin texture, thickness, pigment, or age—generally all adults will absorb the medication at the same rate. Both types of patches can be applied to most areas of the body (i.e., arms, thighs, back, and abdomen); how-
Figure 1. Patient Education for Granisetron Transdermal Delivery Systems • Transdermal patches are waterproof; however, excessive sweat or moisture may cause them to peel off the skin. • Hot, steamy environments (e.g., hot tubs, saunas) should be avoided while wearing a transdermal patch. • Do not apply bath oils or skin moisturizers or use soaps with a high cream content in the area where a patch will be or has been applied. • Cover the patch with clothing and avoid direct sunlight, sunlamps, and tanning beds while wearing the patch and for 10 days following its removal. • Set up a reminder system to ensure the patch is removed at the prescribed interval. • When talking to other healthcare professionals or pharmacists, transdermal patches should be listed among the medications you are taking. Note. Based on information from Schulmeister, 2009.
ever, hair growth may affect adherence, so most manufacturers recommend upper-outer arm placement. Granisetron Transdermal Delivery System Granisetron transdermal patches are of the matrix variety and are designed to deliver 3.1 mg of the drug per 24 hours for up to seven days (for a total of 21.7 mg). However, the patches deliver only about 66% of the drug they contain, so each patch is actually loaded with a total of 34.3 mg of granisetron to allow for the 34% loss. Two double-blind safety studies found that use of granisetron was associated with side effects in 8.7% of patients who wore the patch and 7.1% of patients who received the drug orally. In both groups, the most common side effect was constipation (5.4% and 3%, respectively). The patch had no clinically significant effect on blood pressure or heart rate or rhythm. Patch application site reactions were rare. Efficacy studies of the two routes of administration demonstrated that the drug was effective in 60% of patients who wore the
patch and 64.8% of patients receiving oral granisetron. Schulmeister (2009) noted that no safety and efficacy studies have been completed in patients younger than 18. The patch should be applied to dry, intact skin on the upper-outer arm 24–48 hours before chemotherapy administration and should be removed at least 24 hours after completion of chemotherapy. Gloves do not need to be used for handling the patches. Used patches should be discarded in household waste. To prevent accidental exposure to residual medication by family members and pets, instruct patients to fold the patch in half so it sticks to itself and to wrap it in a paper towel before disposing. For additional patient education points related to granisetron patches, see Figure 1. For more information on the granisetron transdermal delivery system, refer to the full article by Schulmeister (2009). ✱ Schulmeister, L. (2009). Granisetron transdermal system: A new option to help prevent chemotherapy-induced nausea and vomiting. Clinical Journal of Oncology Nursing, 13(6), 711–714.
Daily Doses of Imatinib May Improve Survival for Children With High-Risk Leukemia [By Deborah McBride, RN, MSN, CPON ®, Contributing Editor]
dding continuous daily doses of imatinib to regular chemotherapy doubled three-year survival rates for children with Philadelphia chromosome–positive acute lymphoblastic leukemia (Ph+ ALL), a high-risk type of leukemia, a new study concludes. The Children’s Oncology Group performed the study at 200 North American cancer centers and found that adding continuous exposure to imatinib for 2.5 years increased survival rates to 87% from 30%–35%. Survival rate is the length of time that a patient survived without a relapse and without developing a new cancer. According to the researchers, the drug was well tolerated and had no significant side effects. Multiple types of ALL exist, and each responds differently to treatments. Ph+ ALL involves genetic mutations on two specific chromosomes and doesn’t respond well to chemotherapy. The standard treatment is blood and marrow transplantation, a life-saving procedure but one that is associated with a high risk of complications. Using imatinib in combination with traditional chemotherapy may increase survival time enough so that blood and marrow transplantations are no longer necessary. Imatinib is a pill that is used to treat some adult leukemias and gastrointestinal cancers. It binds to a specific protein in cells and prevents it from proliferating. In this study, 92 children, adolescents, and young adults aged 1–21 with Ph+ ALL received four weeks of standard chemotherapy and then were assigned to five 16
The group that received imatinib for more than 280 continuous days had survival rates of 87%, more than twice that of the histologic control group’s 35% survival rate. different groups that received imatinib Schultz, K.R., Bowman, W.P., Aledo, A., Slayton, W.B., Sather, H., Devidas, M., et al. (2009). Imfor 42, 63, 84, 126, or 280 days. After proved early event-free survival with imatinib treatment, all of the patients received in Philadelphia chromosome-positive acute lymphoblastic leukemia: A children’s oncology maintenance therapy. The group that regroup study. Journal of Clinical Oncology, 27(31), ceived imatinib for more than 280 con5175–5181. tinuous days had survival rates of 87%, more than twice that of the histologic control group’s 35% survival rate. The Contributing Editor Deborah McBride, groups that received imatinib for 84 and RN, MSN, CPON®, is a staff nurse III at 126 days showed moderate improvement the Kaiser Permanente Oakland Medical in survival rates, whereas the groups re- Center and an assistant professor at Samceiving the drug for 42 and 63 days had uel Merritt University in Oakland, CA. the same survival rates as current standard treatments. A comparison group of 21 patients with Ph+ ALL was treated with blood and marrow Oncology Nursing transplantation folForum lowed by six months of imatinib but did not have an increased survival rate. The researchers plan to obtain five-year survival data and then conduct a larger study to compare imatinib and chemotherapy with blood and marrow transplantation to see whether the drug Simply go to www.onsforum.org and regimen can replace click on the podcast link. transplantation. ✱
Journal Experience! Volume 36, Number 2 • March 2009
167 Body Image and Prostate Cancer
232 Reducing Bloodstream Infections in Children
175 Survivor Loneliness After Breast Cancer
ONLINE EXCLUSIVE ARTICLES Strategies for Coping With Taste Changes
185 Predictors of Lymphedema After Surgery
194 Fatigue and Physical Activity in Older Patients
209 Quality of Life and Fatigue in Multiple Myeloma 217 CAM Knowledge and Attitudes
225 Management of Temozolomide Toxicity
Surveillance in Women Undergoing BRCA Testing Patient-Centered Communication
203 Gay and Lesbian Patients With Cancer
Mammogram Use in Korean American Women Perceptions of Patient Knowledge in Decision Making Consolation in Incurable Cancer
An official journal of the oncology Nursing Society www.onsforum.org
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Forum Podcast Series
Prolonged Hospitalization in Patients With Cancer: How Long Is Too Long? [By Jennifer K. Mitchell, MSN, ANP-BC, GNP-BC, Contributing Editor]
ospitalization is often inescapable for patients with cancer. Depending on the type of malignancy, average length of stay (LOS) can vary widely. According to the 2006 National Hospital Discharge Survey by DeFrances, Buie, and Golosinskiy (2008), the average LOS was 6.5 days for patients with a first-line diagnosis of malignant neoplasm and 7.8 days for malignant neoplasms involving the large intestines or rectum. For patients with a hematologic malignancy who did not have renal complications or renal dialysis, the mean total cost was $13,947 for a 7.4 day LOS (Candrilli et al., 2008). LOS also may vary by age, gender, and reason for admission. Although admittance may be for a specific treatment such as induction chemotherapy or surgery, adverse events such as central venous catheter infections and treatment-related complications such as tumor lysis syn-
drome, febrile neutropenia (FN), or acute renal failure can result in significantly prolonged hospitalizations. According to Candrilli et al. (2008), acute renal failure requiring dialysis increases LOS from 7.4 to 17.6 days and increases cost from an average of $13,947 to $44,619. Besides causing emotional distress for patients and the high cost of prolonged hospitalization, a longer stay is associated with acute hospital mortality and mortality following admission to the intensive care unit (Hampshire, Welch, McCrossan, Francis, & Harrison, 2009). According to Nirenberg et al. (2006), patients admitted with FN are at increased risk for adverse events such as acquiring multidrug-resistant pathogens. Additionally, avenues such as IV antibiotic administration and diagnostic procedures put patients at increased risk, and the risk also increases with each hospitalization. Nirenberg et al. reviewed a multicenter, retrospective study of 55,276 patients who were admitted for FN and experienced one complication during the hospitalization and found that the average LOS increased to 11.2 days.
On an institutional level and for individual oncology nurses, the role in decreasing adverse events associated with prolonged hospitalizations involves evidence-based nursing care, continuing nursing research, and ongoing nursing education. For example, hematopoietic colony-stimulating factor (CSF) such as filgastrim and pegfilgastrim has been the single-most useful pharmacologic intervention in reducing the overall adverse events (Nirenberg et al., 2006). National practice guidelines can help identify patients who are high risk for FN and who would benefit from CSF. Day-to-day nursing operations also may decrease hospital LOS, including practicing good hand hygiene, following laboratory trends, and tracking intake/output status to monitor for conditions such as acute renal failure and tumor lysis syndrome. ✱
Candrilli, S., Bell, T., Irish, W., Morris, E., Goldman, S., & Cairo, M.S. (2008). A comparison of inpatient length of stay and costs among patients with hematologic malignancies (excluding Hodgkin disease) associated with and without acute renal failure. Clinical Lymphoma and Myeloma, 8(1), 44–51. DeFrances, C.J., Buie, V.C., & Golosinskiy, A. (2008). 2006 National Hospital Discharge Survey. National health statistics reports. Retrieved August 12, 2009, from http://www.cdc. gov/nchs/data/nhsr/nhsr005.pdf Hampshire, P.A., Welch, C.A., McCrossan, L.A., Francis, K., & Harrison, D.A. (2009). Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: A secondary analysis of the ICNARC Case Mix Programme Database. Critical Care, 13(R137), 1–28. Nirenberg, A., Bush, A.P., Davis, A., Friese, C.R., Gillespie, T.W., & Rive, R.D. (2006). Neutropenia: State of the knowledge part I. Oncology Nursing Forum, 33(6), 1193–1201.
ONS Board Resolves to Help the Society Thrive in 2010 [By Brenda Nevidjon, RN, MSN, FAAN, ONS President]
ypically at New Year’s, we make resolutions, or goals, for the coming year. The ONS Board of Directors has a similar process for setting goals and priorities, using multiple sources of information: your feedback about the organization and our programs and services; trends in cancer care, nursing, and associations; and health policy actions. Here are the Board’s resolutions for 2010 and the next decade. 1. We will be good stewards of ONS resources and ensure that the organization thrives. 2. We will be purposeful with our strategic priorities and encourage outsidethe-box thinking, taking a wide view of issues and trends that influence the care of patients with cancer.
3. We will increase our influence in the health policy arena. We will monitor and influence healthcare reform to improve cancer prevention, access to treatment and clinical trials, and quality of life of patients during and after treatment. We will advocate for inclusive legislative language so nurses are not invisible. As I write this, we know the U.S. House has passed a healthcare reform bill, and the Senate hopes to pass its reform bill by the end of 2009. 4. We are a diverse membership and must ensure that the many constituencies in ONS have a way to express their ideas and needs. We will critically evaluate services provided to our members to ensure that they add
value for oncology nurses and Brenda Nevidjon, patients. RN, MSN, FAAN 5. As a team, we will model open communication and honesty in our discussions, look at all sides of every issue, and work cohesively on behalf of the Society. 6. We will use our vision and mission to guide our decision making. 7. We will ensure that ONS provides expert knowledge, evidence-based resources, and leadership development for all of our members. Of course, individually, we each have goals as you do: Exercise more, eat less, and take more time to relax. Here’s to a great 2010! ✱
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 nurs18
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: Visit www. ons.org.
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: email@example.com • Web site: www.ons.org Oncology Calendar: http://onsopcontent.ons.org/Interactive/EventCalendar
CAREERCENTER 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
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 firstname.lastname@example.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 drugfree workplace.
Pacific Northwest, South Seattle Area Tacoma, Washington MultiCare Health System is searching for a fulltime 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 email@example.com, or fax your curriculum vitae to 866-264-2818. Please refer to opportunity 5802 when responding.
To view ONS’s online Career Center, visit http://careers.ons.org. To place a classified ad, contact Sharon Hampton at Anthony J. Jannetti, Inc. East Holly Ave., Box 56 Pitman, NJ 08071 USA +1-856-256-2300, firstname.lastname@example.org http://careers.ons.org
Do You Enjoy Writing and Reporting? Apply to Serve as an ONS Connect Contributing Editor ONS Connect is seeking a contributing editor (CE) to serve on its editorial board. CEs work on many aspects of ONS Connect production, including writing and editing articles and determining publication goals, policies, and content. Qualified applicants will have an oncology nursing background; experience with newsletter or magazine writing and production; strong reporting, writing, and editing skills; daily access to e-mail; the ability to consistently meet strict production deadlines; and the organizational, planning, and interpersonal skills necessary to learn the role and work independently. The volunteer position requires a two-year time commitment, which includes regular writing assignments, travel to one planning meeting per year (with expenses paid by ONS), and participation in monthly conference calls. Applicants must be ONS members who are RNs. Submit a letter of interest; current curriculum vitae; appropriate supporting materials, including writing samples; and the names of two references by March 30 to Editor Debra M. Wujcik, RN, PhD, AOCN®, via e-mail at ONSConnectEditor@ons.org or fax at +1-615341-4309. January 2010
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