Oncology Nurse Advisor July/August 2018 by Haymarket Media

July/August 2018

www.OncologyNurseAdvisor.com A F O R U M F O R P H YS I C I A N A S S I S TA N T S

ONCOLOGY REHABILITATION FEATURE

The Changing Demographics of Cancer Patient Populations

RADIATION & YOUR PATIENT

Esophagitis: A Common Adverse Effect of Thoracic Radiotherapy

ISSUES IN CANCER SURVIVORSHIP

Five Strategies for Reducing Urgent Cancer Care ED Visits

NAVIGATOR NOTES

Full SDM Discussions Still Lacking in Prostate Cancer

FROM CANCERCARE

Disparities to Disclosure: Lesbians and Breast Cancer

ASK A PHARMACIST

Preparing Chemotherapy Premeds; Herbal Product Information

Staff Education Program Improved Rehabilitation Referrals and Outcomes Subtle changes patients and clinicians often just accept as a “new normal” should prompt a referral to oncology rehabilitation.

PUBLISHING STAFF Editor Joyce Pagán editor.ona@haymarketmedia.com Senior digital content editor Rick Maffei Oncology writer James Nam, PharmD Contributing writer Bette Weinstein Kaplan Group art director, Haymarket Medical Jennifer Dvoretz Graphic designer Vivian Chang Production editor Kim Daigneau Production director Louise Morrin Boyle Production manager Brian Wask brian.wask@haymarketmedia.com Circulation manager Paul Silver

National sales manager Scott Bugni (917) 882-0658 scott.bugni@haymarketmedia.com Account manager Henry Amato (646) 638-6096 henry.amato@haymarketmedia.com

EDITORIAL BOARD Eucharia Borden, MSW, LCSW, OSW-C Lankenau Medical Center Wynnewood, Pennsylvania Ann J. Brady, MSN, RN-BC Huntington Cancer Center Pasadena, California

Manager, Multi-channel business development, Haymarket Oncology Marc A. DiBartolomeo (609) 417-0628 marc.dibartolomeo@ haymarketmedia.com

Jiajoyce R. Conway, DNP, CRNP, AOCNP Cancer Care Associates of York York, Pennsylvania

Managing editor, Haymarket Oncology Lauren Burke

Marianne Davies, DNP, ACNP, AOCNP Smilow Cancer Center @ Yale New Haven New Haven, Connecticut

VP, Content; Medical Communications Kathleen Walsh Tulley General Manager, Medical Communications Jim Burke, RPh CEO, Haymarket Media Inc Lee Maniscalco

Haymarket Media Inc Sales and Editorial offices 275 7th Avenue, 10th Floor, New York, NY 10001; (646) 638-6000

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Oncology Nurse Advisor (ISSN 2154-350X), July/August 2018, Volume 9, Number 4. Published 6 times annually by Haymarket Media Inc, 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M-F, 9am-5pm, ET). Postmaster: Send changes of address to Oncology Nurse Advisor, P.O. Box 316, Congers, NY 10920. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

Frank dela Rama, RN, MS, AOCNS Palo Alto Medical Foundation Palo Alto, California Donald R. Fleming, MD Cancer Care Center, Davis Memorial Hospital Elkins, West Virginia Leah A. Scaramuzzo, MSN, RN-BC, AOCN Kalispell Regional Healthcare Kalispell, Montana Lisa A. Thompson, PharmD, BCOP Kaiser Permanente Colorado Rosemarie A. Tucci, RN, MSN, AOCN Lankenau Hospital Wynnewood, Pennsylvania Kara M. L. Yannotti, MMH, BSN, RN, CCRP John Theurer Cancer Center at Hackensack University Medical Center Hackensack, New Jersey

4 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2018 • www.OncologyNurseAdvisor.com

CONTENTS 17

July/August 2018

IN THE NEWS • CM Use Linked to Higher Risk of Cancer Death • Ado-trastuzumab Emtansine Effective in Other HER2Amplified Cancers • Remission Duration Predicts Long-Term Outcomes in CLL • RT-Induced Nausea and Vomiting Affect Patients and Caregivers Differently • Primary Prophylaxis Key in Reducing Febrile Neutropenia in Early Breast Cancer

• Patient-Provider Conversations on Financial Burden Lacking

......

.....

… and more

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ONCOLOGY NURSE ADVISOR FORUM • Fears Regarding Placebo Use in Clinical Trials • Drug Classification of Trastuzumab

43 22

NAVIGATOR NOTES Full SDM Discussions Still Lacking in Prostate Cancer Megan Garlapow, PhD

FIND US ON

FEATURE Better Staff Knowledge Led to More Rehabilitation Referrals Darcy Kaminen Getzloff, MSN, FNP-BC; Constance J. Creech, RN, MSN, EdD, ANP-BC; Marilyn McFarland, PhD, RN, FNP-BC, CTN-A

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SURVIVORSHIP Exercise Habits Influence Mortality in Adult Survivors of Childhood Cancer

CONTENTS

July/August 2018

Effects of exercise intensity and frequency on mortality among adult survivors of childhood cancers. Bette Weinstein Kaplan

JOURNAL REVIEW FEATURE 32 The Changing Demographics of Cancer Patient Populations Megan Garlapow, PhD

35 37

STAT CONSULT Belinostat (Beleodaq) RADIATION & YOUR PATIENT RT-Induced Esophagitis: A Common Adverse Effect of Thoracic RT Bryant Furlow

COMMUNICATION CHALLENGES Beware Abbreviated Explanations Ann J. Brady, MSN, RN-BC

ISSUES IN CANCER SURVIVORSHIP Five Strategies for Reducing Emergency Department Visits for Urgent Cancer Care Bette Weinstein Kaplan

FROM CANCERCARE Disparities to Disclosure: Lesbians and Breast Cancer Marissa Fors, LMSW

New Recommendations Target Promoting Better Sun Protection Habits for All Patients

USPSTF suggests children and some young adults need better education on sun exposure safety. John Schieszer, MA

Lung Cancer Screening: Effective Models for Selecting the Most Candidates at Highest Risk

Four of 9 screening models effectively select the most appropriate ever-smoker candidates for low-dose CT screening. John Schieszer, MA

THE TOTAL PATIENT Art as Palliative Care: Bedside Intervention Improves Pain, Anxiety, Mood in Hospitalized Cancer Patients

Innovative program demonstrates potential positive effects of brief oneon-one art lessons. Bette Weinstein Kaplan

FROM CANCERCARE The Caregivers’ Cancer Journey

A look at caregivers’ need for evolving support throughout the cancer journey. Caroline Edlund, LCSW-R

ASK A PHARMACIST Preparing Chemotherapy Premeds; Herbal Product Information Lisa A. Thompson, PharmD, BCOP

6 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2018 • www.OncologyNurseAdvisor.com

ON THE

WEB

IN THE NEWS CM Use Linked to Higher Risk of Cancer Death Complementary medicine (CM) practices, a group of wide-ranging interventions (eg, herbs, minerals, traditional Chinese medicines, homeopathy, specialized diets, meditation, yoga), are often used in addition to conventional cancer treatment (CCT) and have been shown to help patients improve their quality of life and feel more hopeful, but its effect on actual survival outcomes are unknown. For this retrospective observational study, researchers accessed the National Cancer Database and evaluated the data of 1,901,815 patients with nonmetastatic breast, prostate, lung, or colorectal cancers. All patients had undergone at least 1 CCT, such as chemotherapy, radiotherapy, surgery, or hormone therapy. Overall, 258 patients were identified as having used CM, and were matched with 1032 patients in the control group. Results showed that although patients who elected to use CM practices did not have a greater delay in initiating CCT, there were higher rates of CCT refusal. Patients who used CM practices had higher rates of refusal for surgery (7% vs 0.1%), chemotherapy (34.1% vs 3.2%), radiotherapy (53.0% vs 2.3%), and hormone therapy (33.7% vs 2.8%). CM practices were also associated with worse 5-year overall survival (82.2% in the CM group vs 86.6% in control group), and was found to be independently associated with a nearly 2-fold increase in mortality risk when treatment delay or refusal were excluded from multivariate analyses. Upon adjusting for treatment delay or refusal, however, no significant associations between CM and an increased risk of death were observed. “Health care professionals need to be proactive in discussing CM and adherence to conventional medicine treatment with their patients,” the researchers noted. “For patients with curable cancers who are inclined to pursue complementary treatment methods, timely adherence to all recommended conventional therapies should be strongly advised.”

Ado-trastuzumab Emtansine Effective in Other HER2-Amplified Cancers HER2 amplication occurs in 2% to 5% of non-breast, non-gastric cancers. Ado-trastuzumab emtansine, a HER2targeted antibody drug conjugate, may have anticancer activity in HER2-amplified cancers. Therefore, researchers at Memorial Sloan Kettering Cancer Center, in New York City, sought to determine the efficacy of ado-trastuzumab in patients with HER2-amplified non-breast, non-gastric cancers. For this multihistology basket trial (ClinicalTrial.gov Identifier: NCT02675829), presented at the 2018 American Society of Clinical Oncology (ASCO) Annual Meeting, researchers enrolled 58 patients with HER2-amplified lung, endometrial,

salivary gland, biliary tract, ovarian, bladder, colorectal, or other cancers; median age was 63 (range, 34 to 90 years); 72% were female. Participants had undergone 1 to 7 prior systemic therapies. HER2 amplification was identified by next-generation sequencing (NGS). Fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) testing was subsequently obtained for tumors with adequate tissue samples. Patients received ado-trastuzumab emtansine 3.6 mg/kg IV every 3 weeks. Primary end point was overall response rate using RECIST v1.1 or PERCIST. Applying a Simon 2-stage optimal design to each histology cohort, type 1 error rate was under 2.7%, power of 89%, H0 10%, H1 40%. In addition, researchers measured duration of response (DOR), progression-free survival (PFS), and toxicity. Continues on page 18

www.OncologyNurseAdvisor.com • JULY/AUGUST 2018 • ONCOLOGY NURSE ADVISOR 17

IN THE NEWS

Read more at https://bit.ly/2M3xqKY.

Primary Prophylaxis Key in Reducing Febrile Neutropenia in Early Breast Cancer Febrile neutropenia is among one of the most common and serious complications associated with chemotherapy. Despite efforts to improve its incidence and outcomes, it continues to worsen quality of life and impede treatment management. For this retrospective study, researchers assessed the outcomes of 524 patients with early-stage breast cancer in 2014 at the Institut Curie, Hospital Rene Huguenin in France, of whom 130 received neoadjuvant chemotherapy and 394 received adjuvant chemotherapy. The majority of patients received 5-FU, epirubicin, plus cyclophosphamide (FEC100) followed by docetaxel. Overall, 17% of study patients developed febrile neutropenia. Eighteen percent of patients (including 74% of those older than 70) received febrile neutropenia primary prophylaxis with granulocyte-colony stimulating factor (G-CSF), 64% of whom received pegfilgrastim. Less than 5% of patients who received primary prophylaxis developed febrile neutropenia. Recurrent febrile neutropenia postsecondary prophylaxis occurred in 9% of patients. Read more at https://bit.ly/2Ouq7gR.

OC Use Not Associated With Increased Melanoma Risk Evidence suggests that the risk of cutaneous melanoma may be modified by female estrogens. Previous studies have found positive associations between oral contraceptive (OC) use and melanoma, but evidence has been conflicting. For the ongoing, prospective E3N cohort study, researchers accessed the French National Education System to evaluate the outcomes of 98,995 French women aged 40 to 65. Participants were instructed to complete a baseline self-administered questionnaire detailing their lifestyles and medical histories, and follow-up questionnaires were sent every 2 to 3 years thereafter.

Of 79,365 evaluable patients, there were 539 cases of melanoma and a total of 966,604 life years was assessed. In age-adjusted models, a modest but positive association was observed between melanoma and ever-use of OCs compared with women who never used OCs, but long-term use of OCs (at least 10 years of life-time use) had a comparable risk with never users. There was an inverse association with age at first use but not with age at last use or time since last use. OC users, however, also had a higher incidence of tanning bed and sunscreen use since age 25, which increases UV exposure and may have influenced the observed correlative effect of OC use and melanoma risk. Read more at https://bit.ly/2OuY69d.

Patient-Provider Conversations on Financial Burden Lacking For a study on clinician engagement, assessment, and communication with patients concerning the financial burden of cancer treatment, investigators sent surveys to nearly 3700 women with early-stage breast cancer between 2013 and 2015 and to their healthcare Financial talks don’t providers. Surgeons, medical oncolomeet patients’ needs gists, and radiation oncologists were also surveyed regarding their experiences with financial toxicity and its management. Of the responding physicians, 50.1% of medical oncologists, 43.2% radiation oncologists, and 15.6% of surgeons stated that financial burden is frequently or always discussed with patients. Survey results indicated that 31.1% of black patients, 30.3% of Latina patients, 25.4% of Asian patients, and 15.2% of white patients wanted to talk to their healthcare providers regarding the financial consequences of breast cancer. However, of the 945 women who expressed financial concerns, more than 72% responded that their healthcare providers and staff were not helpful. Of the 523 patients who wanted to discuss the potential impact on employment or finances, 55.4% reported that they did not have a conversation. The researchers concluded that “improved clinician assessment and communication regarding financial toxicity are necessary. Even physicians who perceive that they are routinely offering necessary services may fail to meet patient needs. Cure at the cost of financial ruin falls short of physicians’ duties.” Read more at https://bit.ly/2OwtYdg.

20 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2018 • www.OncologyNurseAdvisor.com

which consisted of 68% of patients achieving at least very good partial response and 24% achieving complete response. The median progression-free survival was 24.9 months. Treatment response also deepened over a median duration of 36.9 months.

ONCOLOGY NURSE ADVISOR FORUM QUESTIONS & ANSWERS

Our Consultants

FEARS REGARDING PLACEBO USE IN CLINICAL TRIALS Many patients have concerns about enrolling in phase 3 clinical trials that involve placebo dosing, assuming that they may not receive treatment. What should be explained to them regarding placebo use in controlled trials? — Name withheld upon request

Ann J. Brady, MSN, RN-BC, symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.

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

Patients often have fears about enrolling in a clinical trial and potentially not receiving treatment. They need to be reassured that they will receive standard-of-care treatment, at the least. In addition, explaining the following points can help patients understand how placebos are used in clinical trials. A placebo is an agent that has no effect on the disease or patient (sometimes called a sugar pill), and are used in certain phase 3 trials only. Patients must be offered at least the current standard-of-care treatment available for their condition. More importantly, their health care provider would never advocate for a patient to receive a placebo if a treatment is available. Phase 3 trials often compare standard therapy with or without an investigational agent vs the standard therapy alone. These trials are either open label — both clinicians and patients know the treatment being administered — or double blind — neither clinicians nor patients know which treatment is being administered. Placebos are not used in open-label trials. Patients are sometimes disappointed if they are not enrolled into the investigational arm. Often they assume that the investigational arm is going to demonstrate superior response rates than standard of care. This is not necessarily true. The intent of the phase 3 clinical trial is to determine which treatment is more effective in the most patients. Therefore, randomization to receive treatment in the investigational arm of a phase 3 clinical trial is not always better, as some patients respond as well or better when treated with the standard-of-care treatment. — Kara Yannotti, MMH, BSN, CCRP

DRUG CLASSIFICATION OF TRASTUZUMAB With the advent of many immunotherapeutic agents, is trastuzumab (Herceptin) classified as an immunotherapy? If so, how does it work? — Name withheld on request

K. Lynne Quinn, RN, MSN, CRNP, AOCNP, director of oncology, Bryn Mawr Hospital and Bryn Mawr Health Center, Bryn Mawr, Pennsylvania.

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

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

Two hypotheses are discussed regarding trastuzumab as immunotherapy. The literature supports that trastuzumab is an immunotherapeutic agent that stimulates the immune system to promote adaptive immunity; whereas there is also the presupposition that it works by blocking the signaling pathways. Research has labeled trastuzumab as an immunogenic agent but its function in breast cancer is still being discussed. — Jiajoyce R. Conway, DNP, CRNP, AOCNP

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

www.OncologyNurseAdvisor.com • JULY/AUGUST 2018 • ONCOLOGY NURSE ADVISOR 21

NAVIGATOR NOTES

GUIDELINES PSA screening guidelines and the role SDM should play do not always align across organizations, and they are often quickly changing. The American Cancer Society (ACS), American College of Physicians, and American Urological Association emphasize the importance of SDM for PSA testing beginning at age 50 to 55 years.2-4 In 2012, the United States Preventive Services Task Force (USPSTF) recommended against routine PSA testing for patients of all ages, with SDM not coming into play in these recommendations. Nonetheless, they do state that SDM should be used if patients request PSA screening and if healthcare providers continue to provide PSA screening.5 Continuing with the evolution of guidelines, the April 2017 update to the USPSTF recommendations indicate healthcare providers should inform patients ages 55 to 69 about the potential benefits and drawbacks to PSA screening, stating that the decision to

Full SDM Discussions Still Lacking in Prostate Cancer Megan Garlapow, PhD

undergo screening is ultimately up to each patient. The USPSTF gave these updated recommendations a C grade, meaning, “The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient

preferences. There is at least moderate certainty that the net benefit is small.” In clinical practice, it means only selected patients should receive this option, based on individual patient circumstances.6 DISCUSSION ELEMENTS SDM discussions on PSA testing should include 3 elements: the advantages, the disadvantages, and the uncertainties. In this study, SDM comprising 1 element was patients learning only about advantages of PSA screening, 2 elements was patients learning about advantages and disadvantages, and full SDM was patients learning about all 3 elements. Advantages According to the 2017 USPSTF recommendations, PSA screening can identify high-risk, localized prostate cancer that could be successfully treated and can prevent the development of metastatic disease in men 55 to 69 years.6 Guidelines from other organizations generally align with this, and for some patients, screening is an important part of preventive health.2-4 Disadvantages The ACS notes that “although the benefits of prostate cancer screening are uncertain, the burdens associated with the early detection and treatment of prostate cancer are known.”2 In addition, adverse events from therapy can affect urinary, bowel, sexual, and other areas of health. These effects can be temporary or permanent, and minimal or serious. Uncertainties The ACS emphasizes that in men with prostate cancer detected by PSA screening, predicting which patients are likely to benefit from therapy is not possible. Furthermore,

SDM discussions on PSA testing should include 3 elements: the advantages, the disadvantages, and the uncertainties. 22 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2018 • www.OncologyNurseAdvisor.com

eneral consensus across g u idel i ne s suppor t shared-decision making (SDM) between a clinician and patient regarding screening for prostate-specific antigen (PSA). SDM is particularly important as recommendations for PSA screening have changed rapidly over the previous decade and vary based on the recommending body. Although recommendations for PSA screening vary across organizations, most of these organizations now encourage SDM discussions in their recommendations.1

the ACS guidelines note that some men who undergo treatment will avoid death and disability as a result, while others who undergo treatment would have died from unrelated causes prior to the cancer becoming sufficiently serious to affect quality of life or cause death.2 Other guidelines seem aligned with these uncertainties, with the 2017 USPSTF guidelines only conferring a letter grade of C to screening. PSA screening might be associated with a decreased risk of death from prostate cancer, but conflicting evidence exists on the value of screening. IMPLEMENTATION OF SHARED DECISION MAKING

SDM, however, has not been implemented alongside changes in recommendations for PSA screening. A recent study showed no increase in SDM between 2010 and 2015.1 However, although many men in the study were not engaged in SDM, in those who were, a shift toward full SDM rather than only emphasizing the advantages of PSA screening occurred.1 The retrospective, cross-sectional study in men 50 years or older in the United States used data from 2010 and 2015 from the National Health Interview Survey (NHIS). NHIS is run by the Centers for Disease Control and Prevention and monitors health via personal household interviews. Across 9598 data examined, changes from 2010 to 2015 in SDM were stratified based on PSA testing within the previous year or no testing. Overall, participation in an SDM discussion comprising at least 1 element was similar in 2010 (37.2%) and 2015 (37.9%) among all men (P =.958). In men who underwent recent PSA screening, 58.5% were engaged in SDM comprising at least one element in 2010

and 62.6% were engaged in such discussions in 2015, an increase that was not significant (P =.054, adjuster prevalence ratio (aPR) =1.04; 95% confidence interval (CI), 0.98-1.11). In men without recent PSA testing, 54.6% were engaged in SDM comprising at least one element in 2010, and 56.8% were engaged in such discussions in 2015 (P =.448). Notably, though, no overall changes in SDM were seen from 2010 to 2015, in men with recent PSA screening, being informed only of the advantages decreased from 2010 to 2015 (aPR=0.82; 95% CI, 0.71-0.96), and being engaged in full SDM increased during that time (aPR=1.51; 95% CI, 1.28-1.79). In men with no prior PSA testing, 10% reported participating in SDM comprising at least one element at both time points.

innovative strategies are needed to achieve more widespread application of shared decision making,” wrote the authors of one paper.1 With guidelines in place, the behavioral change in healthcare practitioners is critical for the successful implementation of SDM. ■

Behavioral change in practitioners is critical for successful implementation.

3. Carter HB, Albertsen PC, Barry MJ, et al. Early

Megan Garlapow is a medical writer based in Tempe, Arizona. REFERENCES 1. Fedewa SA, Gansler T, Smith R, et al. Recent patterns in shared decision making for prostate-specific antigen testing in the United States. Ann Fam Med. 2018;16(2):139-144. 2. Wolf AM, Wender RC, Etzioni RB, et al; American Cancer Society Prostate Cancer Advisory Committee. American Cancer Society guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin. 2010;60(2):70-98. detection of prostate cancer: AUA Guideline. J Urol. 2013;190(2):419-426. 4. Qaseem A, Barry MJ, Denberg TD, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American

CONCLUSION

Previous research reports SDM is uncommon. Perhaps unsurprisingly, SDM is less common in men who do not undergo PSA screening.1,7 Despite minor improvements in use of SDM, greater improvements are needed to enable patients to work in full communication with their healthcare providers to determine their best choice for PSA screening. “But contrary to guidelines, many men receiving PSA testing still do not receive shared decision making and only 1 in 10 men with no PSA test history received [1 or more] elements of shared decision making. New and

College of Physicians. Ann Intern Med. 2013;158(10):761-769. 5. Moyer VA; US Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(2):120-134. 6. US Preventive Services Task Force. Prostate Cancer Screening Final Recommendation. https://www.screeningforprostatecancer.org. Accessed August 2, 2018. [This reference was updated to reflect the final recommendation statement was released on May 8, 2018. — Eds.] 7. Han PK, Kobrin S, Breen N, et al. National evidence on the use of shared decision making in prostate-specific antigen screening. Ann Fam Med. 2013;11(4):306-14.

www.OncologyNurseAdvisor.com • JULY/AUGUST 2018 • ONCOLOGY NURSE ADVISOR 23

FEATURE | Oncology Rehabilitation

Better Staff Knowledge Led to More Rehabilitation Referrals Educational intervention resulted in significant improvement in identification of need, increased staff communication, and potential for greater referrals.

Physical and psychosocial deficits can be subtle changes patients and clinicians too often accept as a new normal.

DARCY KAMINEN GETZLOFF, MSN, FNP-BC; CONSTANCE J. CREECH, RN, MSN, EdD, ANP-BC; MARILYN McFARLAND, PhD, RN, FNP-BC, CTN-A

here are nearly 14.5 million cancer survivors in the United States, and each year more than 1 million people join this population. Unfortunately, most cancer patients are not adequately prepared for the considerable changes they face in their daily lives, which they often refer to as their new normal.1 These challenges may include pain, depression, lymphedema, swallowing difficulties, neuropathy, reduced range of motion, weakness, and cancerrelated fatigue.2 Cancer prehabilitation identifies a patient’s physical and psychological deficits prior to beginning cancer treatment. Identifying these deficits allows for the use of targeted interventions to help decrease future impairments. Such interventions, therefore, can help decrease readmission rates, length of hospital stays, and direct and indirect healthcare costs.3 Cancer rehabilitation — occurring during and after treatment — is therapy for the deficits that occur as a result of treatment. Rehabilitation is defined as “an effort to maintain or restore function, reduce symptom burden, maximize independence, and improve quality of life [QOL] in this medically complex population.”4 Rehabilitation can occur during treatment, shortly after it, or even years later.2 Oncology rehabilitation programs use a multidisciplinary approach to assess each survivor and provide evidence-based therapies to address and decrease short- and long-term

24 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2018 • www.OncologyNurseAdvisor.com

impairments related to cancer and its treatments, while working to improve survivors’ level of disability.5 LOCAL NEEDS ASSESSMENT Unfortunately, although “functional problems are prevalent among outpatients with cancer, [they] are rarely documented by oncology clinicians.”6 This finding is congruent with what was happening at our project’s setting: a rural oncology clinic in northern Michigan. Many clinic patients were experiencing treatment toxicities, but few were being referred to the oncology rehabilitation program adjacent to the clinic. The researchers hypothesized that increasing referrals to the oncology rehabilitation program could help reduce this gap in care. PURPOSE The purpose of this quality improvement project was to implement an evidence-based staff education program about the need to refer patients to the oncology rehabilitation program. The goals were to improve clinic staff knowledge about an oncology rehabilitation program and to increase patient referrals for treatment- or cancer-related toxicities or impairments. A chart review was conducted to document and compare the referral rates during the 3 months before and after the education program. The oncology clinic staff took pretests and posttests to document their oncology rehabilitation knowledge before and after participating in the education program. LITERATURE REVIEW A literature search of several databases was conducted: PubMed, CINAHL, Up-to-Date, and Medline. The search date range was 2000 to present using the following keywords: oncology rehabilitation, cancer rehabilitation, cancer care, and survivorship rehabilitation. ECONOMIC BURDEN Cancer-related healthcare costs — including costs related to treatment and treatment-related impairments — are expected to reach $155.77 billion by 2018. This amount does not reflect indirect costs such as lost wages, caregiver burden, transportation, and adaptive equipment. In addition, cancer survivors are at increased risk for unemployment and early retirement, and are less likely to be re-employed.7 One study showed that 26% to 53% of survivors lost or quit their jobs in the 72 months post treatment.7 In some cases, survivors’ precancer employment was physically demanding, and they were no longer able to meet these job requirements.8 Cancer site, clinical prognosis, treatment modality, socioeconomic status, and the job itself are

factors that affect survivors’ ability to return to work. In 1960, the 5-year breast cancer survival rate was 63%; today it is 90%. This significant increase in the survival rate means that there could be a larger number of unemployed breast cancer survivors.9 Silver and Gilchrist noted that 26.5% of the population treated for head and neck cancers drive less or not at all after treatment, a fact that could reduce their employability.10 QUALITY OF LIFE Compared with population norms, cancer survivors’ physical and emotional health was reported to be much worse.11 Among persons with a history of cancer, 24.5% reported poor physical health vs only 10.2% of persons without such a history. Poor mental health was reported in 10.1% of cancer survivors vs only 5.99% in a population without cancer. Data extrapolated from this study suggested that 3.3 million cancer survivors have poor physical health and 1.4

The evidence found in the literature review indicates that oncology rehabilitation needs interdisciplinary/ multidisciplinary collaboration. million have poor mental health. The Centers for Disease Control and Prevention (CDC) define quality of life as a “multidimensional concept that usually includes subjective evaluations of both positive and negative aspects of life.”12 One challenge with this concept is that every person, cultural group, or generation defines QOL differently. Health is not the only important factor in QOL. The concept includes multiple domains, including spirituality, housing, jobs, and neighborhoods.12 The CDC uses a set of 4 questions called the “Healthy Days Measure” to evaluate quality of life.13 NEED FOR REHABILITATION SERVICES Many troubling physical and psychological symptoms are related to cancer treatment. Research has shown that less than 30% of the 90% of cancer survivors who need physical rehabilitation services for impairments received such care.3 Banks and colleagues found “the risk of psychological distress in [persons] with cancer relates much more strongly to their level of disability than it does the cancer diagnosis itself.”2 Silver identified 3 major barriers in the provision of oncology survivor treatment: inadequate clinician education about evidence-based treatment, lack of standardization of treatment

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FEATURE | Oncology Rehabilitation evaluations and protocols, and insufficient tracking of patient outcomes.3 In addition to the lack of oncology subtraining received by rehabilitation specialists, another barrier to the provision of survivorship care — a distinct phase of cancer care — is the link between oncology and rehabilitation.10 Cancer and treatment deficits are often thought to be the new way of life and not associated with a rehabilitation potential, so care providers must identify these needs. REHABILITATION CLINIC STAFF The clinical practice team for oncology rehabilitation should be multidisciplinary and include professionals in nursing, physical therapy, occupational therapy, speech, social work, and vocational training as well as a physiatrist trained in physical and rehabilitation medicine. Identifying physical impairments is the essential function of an oncology rehabilitation program, with each provider having a specific role:

• Oncologists and nurses identify deficits and refer patients to the rehabilitation team as appropriate; • Physical therapists focus on alleviating fatigue, deconditioning, and acute and chronic pain, in addition to promoting the ability to move, reduce pain, restore function, and prevent disability; • The physiatrist focuses on function; • The nurse navigator helps patients work through any obstacles they encounter such as treatment barriers; • Occupational therapy focuses on the therapeutic use of everyday activities to improve patients’ ability to participate in the things they want and need to do. • Vocational training, also part of the oncology rehabilitation team’s role, involves assessing job skills and helping survivors retain or find new employment. • Speech therapists’ evaluate swallowing and communication problems. • Mental health professionals work with patients to lessen the psychological impacts of the disease and its treatment. • Pulmonary rehabilitation professionals focus on pre- and posttreatment lung function, which is demonstrated to result in significant improvements in disease- and treatment-related toxicities. The evidence from the studies found in the literature review indicate that oncology rehabilitation needs interdisciplinary/ multidisciplinary collaboration.2-4 IMPLICATIONS FROM THE LITERATURE REVIEW The long-term physical and emotional symptoms cancer survivors experience as a result of their treatments indicate

that cancer care should extend beyond the initial treatment of the disease to include the treatment aftermath. Early screening and treatment through the oncology rehabilitation program can prevent symptoms from worsening and improve current symptoms, even years after treatment. The long-term burden of cancer treatment not only affects survivors, but also society as a whole. The increased financial costs continue to grow due to lost wages and increasing morbidity. Staff participation in oncology rehabilitation referrals has been documented to help ease some of this burden.2 The current body of knowledge demonstrates the need for oncology care to improve physical and psychological QOL as part of each patient’s survivorship journey. Unfortunately, specific studies about oncology care’s role in survivorship QOL are lacking.

Throughout the project, staff were beginning to identify patient impairments and disabilities and discussing them with each other. THEORETICAL INTEGRATION All cancer survivors have views and feelings about their treatment options based on their life experiences and the way health and wellness are viewed in their culture. Therefore, Leininger’s cultural care theory aligns with the work of an oncology rehabilitation program, as the theory views individual patients holistically and culturally.14 Leininger noted that his theory is the “only theory explicitly focused on the close relationship of culture and care on well-being, health, illness, and death.”14 As cancer survivors are presented with the services offered by the oncology rehabilitation program, their previous life experiences and cultural beliefs will affect their decision to accept or decline program services. The same is true for the staff referring survivors to the program: their life experiences and knowledge of evidence-based practice affects their acceptance of the program’s importance and their willingness to promote it among their patients. Staff who work with cancer survivors need to understand key facts: these patients have had many interactions with many different healthcare facilities and providers in their cancer treatment journey, patients’ backgrounds affects their treatment choices, and referrals to the oncology rehabilitation program could help improve patient quality of life. Continues on page 31

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Oncology Rehabilitation |

METHODS The Physician Services Administrator deemed this project a quality improvement project; therefore, it was not subject to Institutional Review Board oversight. EDUCATION PROGRAM Oncology clinic staff participated in an educational program that included definitions of prehabilitation and rehabilitation, a conceptualization of the effects of cancer and its treatments, related evidence-based practice recommendations, and treatments that improve associated impairments. Staff completed pre- and postintervention tests. Two physicians, 1 nurse practitioner, 13 registered nurses, 2 licensed practical nurses, and 2 receptionists trained in medical terminology participated in the educational intervention. CHART REVIEW The study population included patients with a cancer diagnosis who received oncology services at a rural oncology clinic in Michigan’s Upper Peninsula. Because the practice is for adults, all patients were older than 18. A chart review was conducted to document pre- and postintervention rates of referral to the oncology rehabilitation program. The pre-educational review analyzed charts from January through March 2017; the postintervention review was conducted in May through July 2018. RESULTS

The pre- and postintervention referral rates were analyzed via a chi-square test. The referral rate was 2.7% (7/253 patient charts) preintervention, and 4.9% (13/263) postintervention. The percentage rate almost doubled; however, the increase is not considered statistically significant due to the small sample size (x2[1, N=516]=1.107, P =.2927). Mean score achieved by the staff was 20.08 on the pretest and 24.83 on the posttest. A Wilcoxon signed-ranks test indicated this score increase was statistically significant. The P value for the Wilcoxon was P =.002. The standard deviation was 2.610 in the pretest and 0.389 in the posttest. DISCUSSION Although the increase in referrals to rehabilitation was not statistically significant, they were clinically significant. Referrals almost doubled from 7 in 253 patient charts to 13 in 263. As staff’s knowledge of oncology rehabilitation continues to grow, the upward trend may continue, supporting the idea that increased provider knowledge ultimately helps improve patient quality of life. This project measured only the number of patients who accepted referrals, not who received referrals; therefore, the actual number of referrals offered was likely much higher.

FEATURE

Limitations for this project included the small sample size of 19 clinical care providers for pre- and postintervention scores. Although the number of patient cases examined both before and after the intervention period was more than 250, extending the postintervention period could have resulted in additional accepted referrals. The project revealed an outcome not analyzed by the data. Throughout the project, staff were beginning to identify patient impairments and disabilities and discussing them with each other. The project promoted an open dialogue

Increased knowledge led to more patients exposed to information on rehabilitation and a greater identification of patient needs. about oncology rehabilitation referrals among staff, with each asking others to recommend referrals. Patients receiving chemotherapy often are in the clinic for several hours and therefore have much longer interactions with the nursing staff. During this time, the increased knowledge of oncology rehabilitation has given nurses the ability to identify rehabilitation candidates, which may lead to an increase in patients being referred and accepting referrals. CONCLUSION In conclusion, the educational program increased staff knowledge about oncology rehabilitation. And although the increase in referral rate was not statistically significant, the increased knowledge led to more patients exposed to information on rehabilitation and a greater identification of patient needs in this area. Future projects could investigate differences between those patients who accepted referrals and those who declined to identify potential barriers to referral acceptance. ■ Darcy Getzloff is an oncology nurse practitioner; Constance Creech is associate professor, director Graduate Nursing Affairs, School of Nursing; and Marilyn McFarland is professor, School of Nursing; all at the University of Michigan-Flint, in Flint. REFERENCES 1. DeSantis CE, Lin CC, Mariotto AB, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014;64(4):252-271. 2. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. CA Cancer J Clin. 2013;63(5):295-317. References continue on page 34

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FEATURE | Paradigm Shifts in Oncology

The Changing Demographics of Cancer Patient Populations A snapshot of the 4 most commonly diagnosed cancers reveals disparities in the current trends in patient age at diagnosis vs overall costs of cancer care.

Care costs studies focus on patients older than 65, but almost half of new diagnoses involve younger patients.

MEGAN GARLAPOW, PhD

ancer healthcare costs in the United States during the current decade are projected to increase by 27% when accounting for increasing prevalence and may grow by as much as 66% based on increasing treatment costs, according to Matthew P. Banegas, PhD, of the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, and lead author of a recently published study on the economic burden of cancer.1 Cancer treatment has been shown to be more aggressive for patients younger than 65, but care cost estimates tend to focus on patients 65 and older. This disparity could be important considering that almost half of new diagnoses emerge from the younger age group. STUDY DESIGN Healthcare costs associated with breast, colorectal, lung, and prostate cancers — the 4 invasive cancer types most commonly diagnosed in the United States — were evaluated by Banegas and colleagues. During the study period of January 1, 2000, through December 31, 2008, the researchers reviewed electronic health records of 45,522 adults with cancer diagnosed between January 1, 1988, and December 31, 2007, to estimate treatment costs. Costs related to cancer treatment were compared with noncancer treatment costs from controls comprising 314,887 patients whose data were binned for comparisons with costs for patients representing each of the 4 cancer types. All patients included in the study were enrolled in

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healthcare plans from one of the following: Group Health Cooperative (Seattle, Washington), Henry Ford Health System (Detroit, Michigan), Kaiser Permanente Colorado (Denver), or Kaiser Permanente Northwest. Comparisons were made between healthcare costs for patients aged 65 and older and costs for patients younger than 65. Older patients comprised 57.7% of patients with prostate cancer, 59% of patients with colorectal cancer, and 64% of patients with lung cancer. Only 35.9% of patients with breast cancer were from the older group. Breast and prostate cancers were the most common cancer types in this study. THE COST OF CANCER

“Findings from this study address a significant knowledge gap by updating registry-based estimates of medical care costs among US patients with cancer [younger than] 65, and extending studies based on cancer survivors in the MEPS [Medical Expenditure Panel Survey] by providing cost estimates that incorporate key clinical information, such as stage of disease, as well as timing of cancer diagnosis and survival, which enabled estimation of monthly phase-of-care costs,” explained the researchers. Net cancer-related healthcare costs were higher for younger patients than for older patients in all 1- and 5-year comparisons by type of cancer and stage of disease. Net costs were considered to reflect cancer-specific costs and were calculated by subtracting the mean costs for patients in noncancer control populations from the total costs for patients with cancer. Net, rather than total, costs were emphasized in analyses because older-age categories typically showed higher overall healthcare costs. The differences in net healthcare costs by age were quite substantial in some comparisons, with a 1-year mean net cost of $91,800 for younger patients with stage IV lung cancer and $62,300 for patients 65 years and older. The 5-year costs were $172,000 and $124,900, respectively. Costs in this study were reported in 2015 dollars and were inflation-adjusted. For stage IV breast cancer, the 1-year net costs were $87,500 for the younger patients and $43,000 for the older group. The 5-year net costs for stage IV breast cancer were $172,900 for the younger patients vs $77,100 for the older patients. COST RELATIVE TO CANCER STAGE The researchers also found that costs typically were lower with earlier-stage diagnoses. For example, unlike the costs to treat breast cancer at stage IV, the 5-year mean net cost to treat the disease at stage I was $36,000 among younger patients vs $25,200 for older patients.

One-year mean net costs for stage I cancers in younger patients vs older patients, respectively, were $29,100 vs $21,900 for breast cancer, $29,200 vs $26,600 for colorectal cancer, $45,500 vs $35,400 for lung cancer, and $12,900 vs $8,900 for prostate cancer. “Net costs of care were highest for patients aged [younger than] 65 years with advanced-stage cancers, suggesting that early detection and prevention strategies are key to curtailing high long-term costs associated with late-stage disease,” stated the researchers. “This also emphasizes the need for continued effective cancer screening, as outlined by the US Preventive Services Task Force,” they continued. The most common stages at diagnosis in this study varied by cancer type, with stage I representing 55.3% of patients with breast cancer, stage II representing 31.7% of patients with colorectal cancer and 78.9% of those with prostate cancer, and stage IV representing 40.4% of patients with lung cancer. Median survival time was 18.5 months for lung cancer, 79.8 months for colorectal cancer, 177.9 months for breast cancer, and 199.9 months for prostate cancer. THE MOST EXPENSIVE TREATMENTS Lung cancer showed the highest average costs to treat for most time periods and at each stage. However, for younger patients with stage IV colorectal cancer, the 5-year mean net cost surpassed those from the other cancer types in this study, at $179,300 vs $99,900 for older patients. Prostate

A caveat to this study was that costs were incurred prior to inception of the ACA, which was expected to lower healthcare costs overall. cancer was the least expensive to treat at 1 or 5 years for all stages, with treatment for younger patients with stage IV showing a mean net 5-year cost of $43,700 vs $27,300 for older patients. A caveat to this study, pointed out by the researchers, was that the included costs were incurred prior to inception of the Affordable Care Act (ACA), which was expected to lower healthcare costs overall. The researchers also noted that the study’s interpretations may reflect most closely costs related to care at institutions similar to those in the study and possibly be restricted to similar demographics as in the study pool. Furthermore,

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FEATURE | Paradigm Shifts in Oncology costs may even be higher now with newer treatments that have been developed since this study’s data were obtained. Still, this study serves as a point of reference that may enable estimation of healthcare costs due to cancer by monthly phase-of-care and at 1- and 5-year intervals. CONCERNING TRENDS COMPOUNDING THE COSTS “Escalating cancer prevalence points to an increasing demand for cancer care services and underscores the utility of studies that examine the cost of cancer care in formulating future directions and research priorities,” wrote the authors of this analysis, suggesting its connection with the concerning trend of increasing rates of cancer in younger adult patients. In particular, the populations of people in the millennial (20 to 39 years) and generation X (40 to 54 years) generations are experiencing increased incidence of colorectal cancer, according to results from a 2017 study.2 This comes at a time when the incidence of colorectal cancer is declining in older generations.2 Screening and prevention continue to be the best immediate interventions. “Beyond awaiting scientific discovery and the widespread adoption of healthier living, meaningful action can be taken to mitigate premature morbidity and mortality from this disease through educational campaigns about the importance of timely follow-up of CRC symptoms, regardless of patient age, and age-appropriate screening,” concluded the authors of the colorectal incidence study.2

Rehabilitation Referrals Continued from page 31

Though the cause(s) of elevated incidence of colorectal cancer in younger adult generations is unknown, changing trends in cancer among young adults do not appear limited to colorectal cancer. Results from a recent report indicated young American women now experience a higher incidence of lung cancer than young men, a reversal of a bias toward males that is not explained

A cancer-money storm could be on the near horizon. Early detection seems to be the optimal way to improve both clinical and financial outcomes. by sex differences in smoking. The incidence of lung cancer also rose in young Hispanics in the United States.3 With these trends of significantly higher costs of care for cancer in younger patients and rising incidence among the population, a cancer-money storm could be on the near horizon. Early detection seems to be the optimal way to improve both clinical and financial outcomes. ■ Megan Garlapow is a medical writer based in Tempe, Arizona. The references appear in the online version of this article, accessible through this easy link: https://bit.ly/2AdjwEM.

studies and prototypical narratives. Psychooncology. 2010;19(2):115-124. 9. Kirschner KL, Eickmeyer S, Gamble G, Spill GR, Silver JK. When teams fumble: cancer rehabilitation and the problem of the “handoff.” PM R.

3. Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil. 2013;92(8):715-727. 4. Silver JK, Smith SR, Wisotzky EM, Raj VS, Fu JB, Kirch RA. Response to

2013;5(7):622-628. 10. Silver JK, Gilchrist LS. Cancer rehabilitation with a focus on evidencebased outpatient physical and occupational therapy interventions. Am J Phys Med Rehabil. 2011;90(5 suppl 1):S5-S15. 11. Weaver KE, Forsythe LP, Reeve BB, et al. Mental and physical health-relat-

editorial by Richard Crevenna, MD, regarding “cancer rehabilitation and

ed quality of life among U.S. cancer survivors: population estimates from

palliative care: critical components in the delivery of high-quality oncol-

the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers

ogy services” by Silver et al. Support Care Cancer. 2015;23(12):3409-3410. 5. What is the STAR Program? STAR Program Oncology Rehab website. http://starprogramoncologyrehab.com/what-is-the-star-program/. Accessed August 2, 2018. 6. Cheville AL, Beck LA, Petersen TL, Marks RS, Gamble GL. The detection

Prev. 2012;21(11):2108-2117. 12. HRQOL concepts. CDC Centers for Disease Control and Prevention website. https://www.cdc.gov/hrqol/concept.htm. Last reviewed May 23, 2016. Last updated May 31,2016. Accessed August 2, 2018. 13. CDC HRQOL–14 “Healthy Days Measure.” CDC Centers for Disease

and treatment of cancer-related functional problems in an outpatient

Control and Prevention website. https://www.cdc.gov/hrqol/hrqol14_

setting. Support Care Cancer. 2009;17(1):61-67.

measure.htm. Last reviewed October 30, 2017. Last Updated October 30,

7. Mehnert A. Employment and work-related issues in cancer survivors. Crit Rev Oncol Hematol. 2011;77(2):109-130. 8. Steiner JF, Nowels CT, Main DS. Returning to work after cancer: quantitative

2017. Accessed August 2, 2018. 14. Leininger M. Culture care theory: a major contribution to advance transcultural nursing knowledge and practices. J Transcult Nurs. 2002;13(3):189-192.

34 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2018 • www.OncologyNurseAdvisor.com

STAT CONSULT Belinostat (Beleodaq) Drug Type

• Histone deacetylase inhibitor

Indication

• Relapsed or refractory peripheral T-cell lymphoma (PTCL) — Approved under accelerated approval based on tumor response rate and duration of response; improvement in survival or disease-related symptoms has not been confirmed Mechanism of Action

• Belinostat is a histone deacetylase (HDAC) inhibitor that catalyzes the removal of acetyl groups from the lysine residues of histones and some nonhistone proteins • In vitro, this causes a buildup of acetylated histones and other proteins, leading to cell cycle arrest and/or apoptosis Dosage and Administration

• 1000 mg/m 2 IV infusion over 30 minutes once daily • Administered daily on days 1 to 5 over 21-day cycles • 500 mg lyophilized powder single-dose vial for reconstitution — Reconstitute with 9 mL sterile water for injection and swirl until no visible particles — May store reconstituted product for 12 hours at ambient temperature — Withdraw volume needed for required dose and transfer into infusion bag of 250 mL 0.9% NaCl solution ■ May store solution for 36 hours at ambient temperature including infusion time — Do not use if cloudiness or particulates are visible Dose Adjustments

• Absolute neutrophil count (ANC) should be ≥ 1.0×109/L and platelet count should be ≥ 50×109/L before the start

of each cycle and before resuming therapy after toxicity. • Discontinue in patients who have recurrent ANC nadirs less than 0.5×109/L and/or recurrent platelet count nadirs less than 25×109/L after 2 dose reductions • Toxicities must be grade 2 or lower prior to reinitiating therapy • Hematologic toxicities — Platelet count ≥ 25×109/L and nadir ANC ≥ 0.5×109/L ■ No change — Nadir ANC less than 0.5×109/L (any platelet count) ■ Decrease dosage by 25% (750 mg/m 2) — Platelet count less than 25×109/L (any nadir ANC) ■ Decrease dosage by 25% (750 mg/m 2) • Nonhematologic toxicities — Any Grade 3 or 4 adverse reaction (AR) ■ Decrease dosage by 25% (750 mg/m 2) — Recurrence of Grade 3 or 4 AR after 2 dose reductions ■ Discontinue Specific Populations

• Pregnancy: Category D • Nursing mothers — Discontinue nursing or drug, taking into account risk vs benefit of therapy • Pediatric — Safety and efficacy not established • Geriatric — Patients 65 and older have higher response rates than patients younger than 65 — No differences between patients older than 75 vs those younger than 75

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STAT CONSULT • Hepatic impairment ——Hepatic impairment expected to increase drug exposure ——Patients with moderate-to-severe hepatic impairment were excluded from clinical studies. • Renal impairment ——Drug exposure unaffected in patients with CLcr >39 mL/min ——Insufficient data to recommend dose in patients with CLcr ≤39 mL/min. Boxed Warnings and Contraindications

• None Cautions

• Embryo-fetal toxicity ——Can cause fetal harm; may cause teratogenicity or embryo-fetal lethality • Gastrointestinal toxicity ——Nausea, vomiting, diarrhea may occur ——Use antiemetic and antidiarrheal medications as necessary • Hematologic toxicity ——May cause thrombocytopenia, leukopenia (neutropenia, lymphopenia), and/or anemia ——Monitor blood counts weekly during treatment and modify as necessary • Hepatotoxicity ——Monitor liver function prior to treatment and before each cycle ——Interrupt or adjust dose until recovery, or discontinue based on severity • Infections ——May cause fatal infections, including pneumonia and sepsis ——Do not administer to patients with active infection; patients with history of chemotherapy may be at higher risk of threatening infections • Tumor lysis syndrome ——Monitor patients with advanced stage disease and/or high tumor burden and take necessary precautions Adverse Effects

• Most common adverse reactions (more than 25% of patients) ——Anemia, fatigue, nausea, pyrexia, vomiting Drug Interactions

• Avoid concomitant administration with strong inhibitors of UGT1A1

anticancer medication — used to treat patients with a cancer called peripheral T-cell lymphoma (PTCL) • Belinostat is used to treat PTCL that relapses or does not respond to other anticancer therapies • Whether belinostat is safe and effective in children is not known • Belinostat is administered in an IV infusion for 30 minutes ——Treatment is administered in cycles of 21 days each ——The infusion is given on days 1 to 5 of every cycle ——Dose may be changed or stopped if you experience certain adverse effects during treatment • Your blood will be tested before you start treatment and at the start of each cycle • Tell your doctor and nurse if you ——Have an infection ——Have kidney or liver problems ——Have nausea, vomiting, diarrhea ——Have previously received chemotherapy ——Take any prescription or over-the-counter medications, herbal supplements, or vitamins • Belinostat can harm an unborn baby. ——Women of childbearing potential should avoid becoming pregnant while receiving belinostat. ——Tell your doctor right away if you become pregnant. • Nursing mothers ——Belinostat has a potential to create serious adverse reactions in nursing infants ■■ You need to decide with your doctor if you should breastfeed or continue treatment, taking into account the importance of taking the drug to you • Belinostat may cause serious adverse effects, including ——Low blood cell counts: platelets, red blood cells, and white blood cells ——Serious infections: Report any signs or symptoms of infection such as fever, flulike symptoms, cough, shortness of breath, burning with urination, muscle aches, or skin problems ——Liver problems: Tell your doctor if you notice yellowing of skin, dark urine, itching, or pain in the right upper stomach area ——Tumor lysis syndrome: Your doctor will check for this adverse effect while you are receiving treatment ——Nausea, vomiting, diarrhea: Report if you experience any of these symptoms. You may receive medication to relieve these symptoms. • Report any adverse effects you experience that do not go away or bother you.

What to Tell Your Patient

• Belinostat is a histone deacetylase inhibitor — a type of

Prepared by James Nam, PharmD.

36 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2018 • www.OncologyNurseAdvisor.com

RADIATION & YOUR PATIENT

Treatment plan targeting lung cancer (center) superimposed on an MRI of the area

RT-Induced Esophagitis: A Challenge for Thoracic Radiotherapy Bryant Furlow Radiation-induced esophageal swelling (esophagitis) and painful swallowing (odynophagia) are common and debilitating treatment toxicities for patients undergoing radiotherapy for lung, breast, or head and neck cancers or lymphoma, and represent a significant clinical and research challenge. Recent advances in radiographic quantification of esophagitis grade and the identification of candidate predictive biomarkers and multivariate risk-stratification models might lead to more timely detection and management of esophageal radiotoxicities. But the optimal dosimetric strategy for preventing radiation esophagitis has yet to be identified. Several clinical trials are under way to test potential treatments.

cute radiotherapy-induced esophagitis (ARIE) is the most frequent local complication of thoracic radiotherapy; it is debilitating and can cause treatment disruptions and treatment discontinuation, affecting patients’ quality of life and prognosis.1-4 Radiotherapy-induced mucosal inflammation, epithelial ulceration, and spikes in inflammatory cytokines are suspected pathophysiological culprits.3 Higher radiation dose and combined chemoradiation are both associated with the risk of developing esophagitis and painful swallowing (odynophagia).1-3 Some patients develop late esophageal stricture, with similar symptoms — but these cases are more frequently irreversible.3 In general, ARIE occurs within 3 months after completion of radiotherapy; however, typically onset occurs 2 weeks after treatment begins and lasts until 4 weeks after treatment concludes, with progressively worsening odynophagia, nausea, dysphagia, and, if ineffectively managed, anorexia.1,3 Late radiation esophagitis occurs more than 3 months after radiotherapy ends, with an average time from treatment to symptom onset of 6 months.3 Radiation esophagitis ranges from asymptomatic or mild fibrosis and slight difficulty with swallowing solid food to severe ulceration, fibrosis, perforation, necrosis, and even fistula.2,3 Severity is graded on a scale of 1 to 5: grade 1 represents clinically or radiographically detected and asymptomatic; grade 2 and 3, symptomatic with altered eating habits; grade 4, life-threatening requiring invasive intervention; and 5, patient death.3 CURRENT AND POTENTIAL TREATMENTS

Grade 2 esophagitis is treated with oral dietary supplements; grade 3 usually

requires hospitalization and tubal feeding or total parenteral nutrition. 3 Diagnostic imaging plays an increasingly important role in quantifying, characterizing, and grading radiation esophagitis.5 Ex per i ment a l t reat ment s for ARIE currently undergoing clinical testing include manuka tree honey (ClinicalTrials.gov identifier: NCT01262560), oral epigallocatechin3-gallate (EGCG 6; ClinicalTrials. gov identifier: NCT02577393), glutamine (ClinicalTrials.gov identifier: NCT01952847), and doxepin hydrochloride (ClinicalTrials.gov identifier: NCT02062632). Investigational radioprotective agents such as amifostine have been studied as preventive agents but have not been shown to be protective against high-grade radiation esophagitis.3 Low-grade esophagitis is currently managed with analgesics and anesthetics such as benzocaine, antiviral and antibacterial agents, anti-inflammatory corticosteroids, acid suppression (eg, ATPase inhibitors such as omeprazole) — and importantly, dietary change.1-3 Anorexia is a common complication of ARIE; referring patients with ARIE to a nutritionist can help patients maintain nutrition despite painful or difficult swallowing.1-3 Severe cases are typically treated with endoscopic dilatation or surgery, but can persist even after these invasive interventions.3 Clinical and radiographic scoring systems can objectively quantify the severity of ARIE and late-radiation esophagitis and efforts are underway to scientifically evaluate the reliability of patient self-report-based scoring systems. For example, computed tomography (CT) scans can be used to help grade ARIE severity.5 However, development of more strongly predictive biomarkers and

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RADIATION & YOUR PATIENT models are urgently needed to reliably identify those patients who face the highest risk of experiencing ARIE or late radiation esophagitis.7-12 Metabolic or functional imaging with 18 F-fluorodeoxyglucose positron emission tomography (FDG PET) can be used to detect early esophageal changes that are predictive of high grade (grade 3) ARIE 2 weeks after initiation of radiotherapy.7 PREDICTING RADIATION ESOPHAGITIS

Accurately predicting radiation esophagitis and odynophagia is an important goal for patient risk stratification, treatment planning, monitoring, and timely interventions. Currently, however, there are no definitive, universally employed systems for doing so.

Radiation dose to esophageal mucosa is a well-established risk factor for ARIE.

up to 20% incidence of grade 3 or higher radiation esophagitis, and there is also evidence that the proportion or percentage of the esophageal mucosa receiving more than 50 Gy total radiation dose is predictive of radiation esophagitis.3 However, there is not yet consensus about the optimal dosimetric prediction.3 Dose-based r isk prediction is strengthened when included in multivariate statistical models alongside biomarkers such as baseline levels of inf lammatory cytokines (eg, interleukin 8 [IL-8]).1-3,8-12 Elevated serum levels of certain non-gene-coding micro-RNAs at 2 weeks after treatment begins might also predict severe ARIE.14 But until large, randomized prospective validation trials are conducted, these biomarkers and multivariate models will remain investigational. ■

6. Zhu W, Zhao H, Chen G, et al. Oral epigal-

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

10. Hawkins PG, Boonstra PS, Hobson ST, et

induced esophagitis in patients with esophageal cancer receiving chemoradiation therapy/radiation therapy. Int J Radiation Oncol Biol Phys. 2016;96(2 suppl):E581. 7. Mehmood Q, Sun A, Becker N, et al. Predicting radiation esophagitis using 18FFDG PET during chemoradiotherapy for locally advanced non-small cell lung cancer. J Thorac Oncol. 2016;11(2):213-221. 8. Wang S, Campbell J, Stenmark MH, et al. A model combining age, equivalent uniform dose and IL-8 may predict radiation esophagitis in patients with nonsmall cell lung cancer. Radiother Oncol. 2018;126(3):506-510. 9. Paximadis P, Schipper M, Matuszak M, et al; Michigan Radiation Oncology Quality Consortium. Dosimetric predictors for acute esophagitis during radiation therapy for lung cancer: results of a large statewide observational study. Pract Radiat Oncol. 2018;8(3):167-173. al. Prediction of radiation esophagitis in non-small cell lung cancer using clinical

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Women, white patients, patients with existing gastroesophageal reflux or poor baseline performance status, and low body mass index (BMI) are at greater risk of developing severe ARIE than are other patients.3 The role of age in radiation esophagitis risk is less clear; it was long believed that elderly patients (70 years or older) are at increased risk of ARIE, but recent studies suggest a lower incidence among elderly patients.3,13 Radiation dose to esophageal mucosa and other esophagus tissues is a wellestablished risk factor for ARIE. Esophageal radiation dose is predictive of ARIE; mean whole-esophagus dose less than 34 Gy is associated with

locatechin-3-gallate treats acute radiation-

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Radiother Oncol. 2014;113(3):379-384.

42 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2018 • www.OncologyNurseAdvisor.com

COMMUNICATION CHALLENGES

Ann J. Brady, MSN, RN-BC, CHPN

....... .....

......

... We know what we mean when we say something, yet the message patients hear may not be the one we intended.

hildren can be unbelievably wise. Unhampered by social expectations, they say exactly what they think. My sweet grandson was recently hospitalized and required antibiotics for an infection. He is only 5. When the kind and very capable pediatric nurse was starting his IV, he was not happy about it. But even so, he sat still while she set everything up and tried to place the IV. Unfortunately, she could not thread the catheter which meant she had to try again. As she got everything ready for the second try she tried to console him by saying, “I’m so sorry. I have to try again. It’s going to be okay.” His response was unfi ltered and immediate. “It is not okay.” He looked especially small in the big hospital bed, punky and droopy eyed. Yet he was clear and strong voiced when he added, “I did not give you permission.” Of course, he was crying and wiggling around as he said it, after all, he’s a 5-year-old. With or without permission he needed the IV and she expertly placed it

the second time. I don’t know how pediatric nurses do it but they have my respect. As anxious as I was in the moment, he’d been febrile for nearly 3 weeks and no one could figure out what was going on, and despite those concerns, I smiled when he said it. Because, of course, he was right. He had not given anyone permission. It was not okay. And yet they were doing things to him that he did not want. I was amazed at how articulate he was for a 5-year-old. What is the old saying? Out of the mouth of babes. Fortunately, a course of antibiotics was all he needed and he recovered quickly. The idea of what he said stayed with me. The experience of him vulnerable and in the hospital made me think of my oncology patients. I know they don’t look the way they would if they were up and walking around; at least logically I can think that. Yet I am presented with them as they are, hospitalized and ill, looking punky and droopy and not at all themselves. Even when I’ve never met them, I know I am not seeing the person they see themselves as. They undergo so many things: surgery, IVs, chemo, all kinds of side effects. More doctor appointments and testing than anyone would ever like to have. Given half a chance, instead of sitting quietly and letting us care for them they might say, “I did not give permission to be sick.” No one wants to be sick and go through all of that. Of course, some might argue that they consented for all of the interventions, but truly, they have no more control than my little grandson did. This made me think of the times I’ve tried to console or soothe and said, “It’s going to be okay.” What I meant is that I was there to help care for them. What I meant was I anticipated a good response to chemo or a

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COMMUNICATION CHALLENGES

We can reconsider the words we use and hopefully get closer to communicating effectively.

reversal of low blood counts or the clearing of a secondary infection. Those are the “it’s-going-to-be-okay” sayings that are temporary or fi xed on a particular small situation rather than the larger one at hand. How often do we truly understand the loss of control our patients experience? How many times have our patients faced a second or third hospitalization or complication? What do those words mean to them? DISCUSSION When it comes to communication challenges some of the most complicated are the technological advances in communication. Our smart phones and computers — with instant messaging, texting, and emails — are touted as a way to stay in touch. Smart, easy, accessible. Like most folks I use my smart phone to text messages as a quick way to reach people. It feels less intrusive than an outright phone call. I can send a message and cross it off my checklist. Recently my brother and I were exchanging texts regarding plans to meet. I was certain the message I sent was perfectly clear, yet he read it and interpreted it slightly differently. It was a surprise to both of us when we realized we had miscommunicated. I went back and reread the original text. It had the information I meant to convey but the nuances were not there. I realized that the meaning I attached to the message, which originated with my own

understanding, was not clearly there. And he read the text with his own understanding of what I said. Assumptions were made on both sides. When we read or write a text message, we do so with something clear in our mind. We send the message and are confident it is read the way we intended it, which is not always the case. The same shorthand communication can happen when we are caring for our patients and families. We know what we mean when we say something, yet the message they hear may not be the one we intended. What they hear us say is fi ltered by their own preconceptions. The pediatric nurse said to my grandson, “It’s going to be okay,” and she meant it. She knew she would get the IV started. She knew the antibiotics would help him. She knew all of these things. Because he was 5, he wasn’t able to understand on a deeper level. Her okay was meant to soothe him. In the same way, without intending to, we may give an abbreviated explanation to our patients and inadvertently make an assumption about their level of understanding. Or they may assume they understand your meaning and not ask for an explanation. Just as we re-read a text or an email, we can reconsider the words we use and hopefully get closer to communicating effectively. ■ Ann Brady is a symptom management care coordinator at a cancer center in Pasadena, California.

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Five Strategies for Reducing Emergency Department Visits for Urgent Cancer Care Bette Weinstein Kaplan

mergency departments (EDs) are fraught with all sorts of risks for healthy people, much less for people with cancer. Yet a patient with cancer who experiences a complication of the disease or its treatment may very well end up in the ED, which is frequently a portal to hospitalization for these patients. Surely there is a better way.1 Actually, there is. In a recent report, researchers at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia, describe clinical approaches that can reduce the occurrence of unplanned acute care visits for patients with cancer. The strategies are the result of a review of best practices for reducing unplanned acute care ED visits for patients with cancer, several professional organizations’ quality guidelines, and 5 highquality oncology care delivery models. The most common reasons cancer patients seek acute care are pain, fever, abdominal and respiratory concerns, and dehydration. Treatment is rendered in 1 of 3 settings: the emergency

Many unplanned ED visits were patients having a need to talk with their physician.

department, acute hospitalization, or 30-day rehospitalization. The group found that all-cause hospitalizations — both planned and unplanned — are the most commonly reported acute care events. Examples of planned vs unplanned include scheduled chemotherapy admissions, staged cancer surgeries, and scheduled stem cell transplantation vs nausea and vomiting, neutropenic fever, and symptomatic cancer progression. EFFECTIVE STRATEGIES

The researchers evolved the following 5 strategies for reducing acute care visits for patients with cancer. Identifying patients at high risk for unplanned acute care allows oncologists to focus their resources on specific patients who may benefit from additional support. For example, stratify patients using established risk-stratification models and monitor those with known risk factors accordingly. Enhance access and care coordination

by providing flawless and reliable ways patients can contact their care team, develop patient navigator programs, and improve and standardize transitions of care. Many unplanned ED visits were the result of patients having a need to talk with their treating physician. Standardized clinical pathways for symptom management can reduce unplanned acute care by integrating

supportive care in various areas. This may involve acute symptom management and telephone triage systems, disease management pathways that incorporate supportive care, and symptom management pathways for the ED. Develop new loci for urgent cancer care instead of automatically admitting those patients who present to a general ED. These patients often present during normal clinic hours, so directing them to an alternative setting for care may be feasible. Possible interventions include establish an area for acute cancer observation and treatment within the clinic, embed cancer care clinicians in the ED, or establish a dedicated cancer ED. Use of early palliative care, which is now recommended for all chronic or long-term diseases and patient situations, not only cancer. There should be standardized education regarding symptom management, end-of-life discussions, guidelines for inpatient and outpatient consultation, embedded outpatient palliative care clinics, and integrated inpatient palliative care/oncology units. ■ Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey. REFERENCE 1. Handley NR, Schuchter LM, Bekelman JE. Best practices for reducing unplanned acute care for patients with cancer. J Oncol Pract. 2018;14(5):306-313.

www.OncologyNurseAdvisor.com • JULY/AUGUST 2018 • ONCOLOGY NURSE ADVISOR 45

FROM Disparities to Disclosure: Lesbians and Breast Cancer Marissa Fors, LMSW

outreach to the LGBT [lesbian, gay, bisexual, transgender] population about cancer risk, especially images displayed at walks, awareness activities, etc. It is a very heteronormative type of imagery. Many lesbians don’t see themselves reflected in those images and, in turn, might not see themselves at risk. There may be misconceptions about scheduling screenings that would detect cancers earlier. If they do not perceive themselves at risk, and it is not being reflected back to them, they may opt out of these services. We in the cancer communities need to do a better job of connecting the dots for all women, especially those that the research tells us are at higher risk. FORS: Fears of discrimination and mistrust are present for many lesbians. They may decide whether or not to disclose their sexual orientation based on the fear that this will lead to less support from their healthcare providers.1 Considering this, is it helpful for patients to share their sexual orientation with their healthcare team? How can we create a safe environment for doing so? DR DAMASKOS: The simple answer

diverse group of women. Our conversation begins with Dr Damaskos addressing breast health community outreach and its current limitations. DR DAMASKOS: The jury is still out in

terms of accurately explaining what is going on with such a diverse group of people as lesbians and the risk factors they face. A real problem is how we

is “Yes.” Practitioners need to understand the person in front of them is an individual with her own personal history. These patients have intersecting identities — lesbian, Asian American, mother, professional athlete, etc — that contribute to their health, strengths, and risks. The more patients feel comfortable disclosing their sexual identity, the better it is for their overall care. Treatment centers can provide gaypositive literature in the waiting room

We in the cancer communities need to do a better job of connecting the dots for all women, especially those at higher risk. 46 ONCOLOGY NURSE ADVISOR • JULY/AUGUST 2018 • www.OncologyNurseAdvisor.com

dentifying the unique challenges of specific patient populations with breast cancer must be a priority to provide complete care for the whole person. This sentiment could not be truer for women who identify as lesbian, who often feel invisible and misunderstood by the healthcare system. This interview serves as a platform for a much-needed conversation about disparities experienced by this patient population and as a conduit for proposed strategies to overcome barriers to care. Providing a deeper understanding of stressors unique to lesbians is crucial for a culturally competent and inclusive practice that promotes respect and support. Some studies show that lesbians have a higher risk of breast cancer. The research indicates that this is not due to sexual orientation but to shared risk factors including not having children; having children later in life; and having higher rates of obesity, smoking, and alcohol use (P. Damaskos, PhD, LCSW, OSW-C, oral communication, April 2018). Many lesbians may not seek screening due to a perceived low risk of breast cancer and stressors associated with mistrust of the healthcare system. Fears of discrimination and stigmatization when disclosing one’s sexual orientation increase stress and may delay treatment, contributing to poorer outcomes.1 I spoke with Penelope Damaskos, PhD, LCSW, OSW-C, director of social work at Memorial Sloan Kettering Cancer Center, who shared her expertise on these disparities. Dr Damaskos discussed disclosure and barriers to care, and offered suggestions on how a more inclusive message could be effective in supporting this

to demonstrate a place that is inclusive, signaling that LGBT persons are not an invisible population. Centers can also use a more inclusive registration form with questions about marital status and gender identity beyond the male/female wife/husband binaries, also signaling an open and understanding environment. How patients are questioned about their lives and partners, without making assumptions, will go a long way toward making lesbian women feel understood by their healthcare providers and ultimately more open. FORS: Can you discuss other distinctive

challenges and stressors, and how professionals can recognize and address them?

from a strengths-based perspective. What coping mechanisms have they used in the past? Who are their supports and how reliable are they during a crisis such as cancer? For some lesbians, there could be an increased history of trauma. A cancer diagnosis may resurface that vulnerability unexpectedly within interactions with their medical team.

It is up to us to educate ourselves and utilize resources for LGBT education.

DR DAMASKOS: Consider past and pres-

FORS: How can we be more inclusive in

ent experiences with discrimination or insensitivity and how that can lead to mistrust. Stigma, anxieties about discrimination, expectations of not being supported are all stressors that lesbians may face, and may not be present in the same way for heterosexual women. There has been research that points to high minority stress levels in LGBT populations. Living with this constant stress can cause people to experience more vulnerability in crisis situations such as a cancer diagnosis. Being aware of stressors and how they are managed in other life circumstances is crucial. It is important to meet patients

the way we support lesbians with breast cancer, their families, and loved ones? DR DAMASKOS: Use language that reflects understanding and inclusivity, and understanding of family dynamics. Again, don’t make assumptions. Ask questions that do not assume the gender of someone’s spouse/partner, and don’t put limitations on how patients can identify significant caregivers and partners. It is up to the individual to decide how they identify themselves and who they identify as family. The key is to be accepting and curious in a way that allows practitioners to provide

more holistic care that is understanding of the individual within their whole environment. It is up to us to educate ourselves and utilize resources designed for LGBT practitioner education through professional associations for nurses, social workers, and physicians. Professionals can seek information and guidance from many LGBT resources, including the Gay and Lesbian Medical Association and National LGBT Cancer Network. FORS: I would like to extend my

extreme gratitude to Dr Damaskos for her contribution to this dialogue and commitment to increasing awareness on such an important issue. Recognizing these factors for lesbians with breast cancer is just the beginning. Healthcare professionals must apply this knowledge in their practice and make it a priority to create safe environments, free of stigma, marginalization, and oppression. When our focus shifts to building practices that are inclusive, accepting, and supportive, we create atmospheres that are safe for all patients to receive the care they need and deserve. ■ Marissa Fors is director, Susan G. Komen® Breast Care Helpline at CancerCare. REFERENCE 1. van Dam MA, Koh AS, Dibble SL. Lesbian disclosure to health care providers and delay of care. J Gay Lesbian Med Assoc. 2001;5(1):11-19.

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ASK A PHARMACIST

Preparing Chemotherapy Premeds; Herbal Product Information Are there resources that outline if chemo premeds must be mixed in the laminar air flow hood or can they be mixed in the pharmacy on the counter with no hood? — Marsha Ellison, RN, BS

Hazardous medications must always be manipulated in an appropriate biological safety cabinet (BSC) to prevent exposure to staff. With nonhazardous medications such as chemotherapy premedications, the risks of compounding outside of a hood and cleanroom include the risk of microbial contamination compromising the final product and exposing the patient to an infection risk.

The United States Pharmacopeia (USP) <797> chapter on pharmaceutical compounding of sterile preparations provides guidance and outlines requirements for sterile product compounding, including immediate use and low-, medium-, and high-risk preparations. These regulations are currently being revised, so additional requirements or classifications may be in the updated publication (anticipated December 2019). For more information, visit www.usp.org/compounding/ general-chapter-797. State boards of pharmacy, Joint Commission, other regulating bodies, and your organization may also have additional regulations for sterile product preparation beyond those listed in USP <797>, so I would defer to the advice of your pharmacy leadership. What are some helpful Internet resources for patients to find reliable information about herbal products?

• Memorial Sloan Kettering Cancer Center maintains a database on multiple herbs and dietary supplements: About Herbs, Botanicals & Other Products. • The American Cancer Society website contains information to help patients evaluate information from other sources, and to facilitate conversations with their health care providers. The section also includes information specifically pertaining to marijuana use related to cancer: Complementary and Alternative Medicine. • The National Institutes of Health National Center for Complementary and Integrative Health maintains a database of general information on herbs and supplements that may be particularly helpful for patients wishing to take herbs or supplements for other medical conditions besides their cancer diagnosis: Health Topics A-Z.

— Name withheld on request

Unbiased, evidence-based resources can be difficult to access without a subscription fee. An Internet search typically results in sponsored websites or those geared toward selling products to patients with cancer or their caregivers. Fortunately, there are some helpful, nonbiased websites available. Here are a few that I have used to answer questions about supplements and that I recommend to patients when asked for information resources.

Supplements may interact with the metabolism of medication, antagonize the mechanism of action, enhance toxicity, or otherwise interact with chemotherapy or radiation cancer treatments. Even if the above websites are used, patients and caregivers considering herbal supplements for their cancer or during their cancer therapy should be advised to discuss them with their oncology care team to minimize unintended effects of their supplements on their cancer treatment. ■

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

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