The overall goal is to update the healthcare professional’s knowledge of cancer detection and prevention and to understand current and new research regarding state-of-the-art care for those with or at risk for cancer.
Intended for advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients.
Upon completion, participants should be able to:
Dannemiller is approved by the California Board of Registered Nursing, Provider Number 4229, for 1.0 contact hour. CBRN credit is not accepted by the Michigan and Utah State licensing boards.
The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
This activity is provided free of charge to participants.
A telephone-based symptom monitoring and coaching system not only alleviated hospice patients’ symptoms during their final weeks of life, it also improved the wellbeing of family caregivers, according to a new study presented at the 2014 ASCO Palliative Care in Oncology Symposium.
“Within hospice care, there is this important triad that is made up of the hospice nurse, the dying patient, and the family caregiver,” Bob Wong, PhD, director of applied statistics and research associate professor, College Of Nursing, University of Utah said at a presscast held in advanced of the symposium. In previous studies, automated symptom monitoring systems have been only used to measure feasibility or satisfaction of care. In this study, the automated, telephone-based symptom monitoring system used computer-based technology to have “conversations” with family caregivers about the patient’s symptoms in the past 24 hours as well as the caregivers’ own well-being.
The study compared the symptom care intervention with usual care (symptom reporting alone) of 319 families enrolled in one of 12 hospices in Illinois, Massachusetts, Oregon, or Utah. About half of the families (n = 153) were assigned to receive the symptom care intervention while the remaining families received usual care. The caregivers using the symptom care intervention called in every day and reported on 11 different patient symptoms, such as pain, difficulty breathing, or change in thinking, as well as 5 of their own symptoms, such as fatigue, anxiety, and trouble sleeping. The caregiver was asked to rate these symptoms on a 0 to 10 scale, with 0 being no presence of the symptom.
While both the control group and the intervention group called in and reported the symptoms, the intervention group received additional support. If a caregiver from the intervention group reported an unrelieved symptom (any symptom reported as a 4 or higher), it was reported to the family’s hospice nurse.
The intervention group received automated coaching to improve the caregivers’ family member’s comfort as well as tips to address their own well-being. This included suggestions such as how to position their family member for greater comfort, or improve breathing, or improve time together such as looking at old photo albums. For caregivers, suggestions included how to organize other people to assist, how to schedule time for self, how to improve sleep, or how to decrease anxiety and deal with sadness. Coaching would also normalize the end-of-life symptom experience and help to explain what was happening and what they should discuss with their hospice nurse.
The study found that family caregivers greatly benefited from monitoring and coaching and experienced 44% fewer days of moderate or severe symptoms compared with the usual family caregiver group. Patients in the intervention group reported less severe fatigue and anxiety than the control group.
For a commentary on this article, I have to first acknowledge that the idea a computer-operated communications system can assess hospice patients’ caregivers needs seems farfetched. I am obviously wrong about this.
I have been an oncology nurse for 10+ years and initially I thought we needed the tenderness and empathy of the hospice nurse to provide excellent care. But, with the growing demands on our nurses and our healthcare, it seems like a fresh and appropriate study would be to involve a computer to communicate and to help with the stressors associated with hospice patients and caregivers. I am convinced this approach works because of the attention and time it spends with the caregivers.
Nevertheless, I do not think every family at this time would be willing to enroll in a program like this nor would they be consistent about completing the daily surveys. However, this type of program has high utility and obvious benefit to the caregivers and nurses. I imagine this will be a huge asset to our healthcare and hopefully help contain our spending and improve our overall care.
A systematic review of published results from 203 randomized clinical trials, involving more than 80 different integrative therapies, has yielded evidence-based recommendations for clinicians and their patients with breast cancer about which of these therapies may be most helpful to manage their symptoms. The recommendations also identify complementary interventions for which not enough evidence of benefit currently exists, as well as those deemed unlikely to provide any help.
This research forms the basis of newly published guidelines appearing online in the Journal of the National Cancer Institute Monographs and issued by the Society of Integrative Oncology (SIO). The goal of the new guidelines is to provide an evidence base for shared decisionmaking between clinicians and patients with breast cancer—the majority of whom, studies show, use complementary therapies (between 48% and 80% in North America). Worldwide and for all types of cancer, approximately 33% to 47% of patients use these therapies to complement standard care.
“Most breast cancer patients have experimented with integrative therapies to manage symptoms and improve quality of life,” noted lead author and SIO president Heather Greenlee, ND, PhD, “but of the dozens of products and practices marketed to patients, we found that only a handful currently have a strong evidence base.”
To develop the new guidelines, researchers searched nine databases (EMBASE, MEDLINE, PubMed, CINAHL, PsychINFO, Web of Science, SCOPUS, AMED, and Accutrial) for studies published between 1990 and 2013 which evaluated the safety and effectiveness of integrative approaches used in the context of supportive cancer care.
The search generated 4900 unique articles and was then refined to include only those based on results from randomized clinical trials and those in which the patient cohort included at least 50% with a breast cancer diagnosis and/or trials reporting breast cancer–specific results; 203 articles met the criteria for final review. A panel of multidisciplinary experts in oncology and integrative medicine was convened to prepare the clinical practice guidelines, and the group used the Institute of Medicine’s guideline development process to direct its work.
Greenlee, an assistant professor of epidemiology at Columbia University’s Mailman School of Public Health, noted that the new science-based guidelines should serve as an important tool to support clinicians and their patients in assessing the risk–benefit ratio for each therapy. The expert panel also organized the therapies around specific symptoms to make them more practical for use in the clinic, eg, anxiety, depression, sleep quality, pain, and lymphedema—assigning a grade to various complementary interventions commonly used to manage these symptoms, based on the evidence.
Complementary therapies which showed demonstrable benefit in randomized clinical trials include meditation, yoga, and relaxation with imagery. These interventions received an A grade based on a modified version of the US Preventive Services Task Force grading system which was used to develop the SIO guidelines, and these approaches are recommended for routine use for anxiety and mood disorders. These same practices also received a B grade for reducing stress, depression, and fatigue. Massage also received a B grade for improving mood disturbance in post-treatment survivors.
The authors also noted promising evidence on the use of acupuncture for nausea, fatigue, anxiety, pain, and quality of life, although the modality did not achieve grade A or B on the scale. Similarly, the use of acupressure and ginseng for fatigue, and ginger for chemotherapy-induced nausea and vomiting (CINV), show potential for verification of benefit through further study.
Although 30 interventions received a C grade and did not have sufficient evidence to support specific recommendations, “This does not mean that they don’t work,” stressed Greenlee. “This means that we don’t yet know if they work, in what form, or what dose is most effective.”Other complementary therapies in this category include healing touch and hypnosis for pain, manual lymph drainage and low-frequency laser therapy for lymphedema, especially for survivors who are unable to tolerate compression bandaging, and acupuncture for improving depressive symptoms in women experiencing hot flashes.
Seven therapies were deemed unlikely to provide any benefit, and one therapy which has been marketed to prevent chemotherapy-related neuropathy, acetyl-L-carnitine, was found to be harmful and actually increased the risk for the condition
The researchers stressed the importance of ongoing assessment of the impact of the complementary interventions, even those which their scientific review deemed beneficial. Included in the published guidance is a recommendation that patients using these therapies be monitored for “efficacy and toxicity, including futility and adverse effects.” They also recommended that patients be encouraged to maintain symptom logs.
SIO intends to update the breast cancer guidelines every 3 years. It has previously issued and updated general practice guidelines for integrative therapies, as well as those specific to patients with lung cancer.
Guideline authors, among them, Debu Tripathy, MD, professor and chair of Breast Medical Oncology at MD Anderson Cancer Center, see integrative oncology as an area ripe for further research to address unmet patient needs.
“A challenge in assessing the safety and effectiveness of complementary therapies was the lack of standardization of interventions across trials using similar therapeutic approaches,” said Tripathy. The authors suggest incorporating assessment of integrative therapies as part of conventional treatment trials.
“The vast majority of therapies require further investigation through well-designed controlled clinical trials,” said Greenlee.
Evidence-based recommendations regarding complementary therapies to help alleviate cancer-related symptoms offer clinicians’ additional ways to help improve quality of life measures, such as stress, depression, fatigue, and pain for patients with cancer. Complementary therapies often focus on the mind–body connection and help patients’ learn to cope with symptoms through relaxation-based therapies.
Published guidelines make it easier for providers to reference the benefit of these therapies and encourage patients’ interest and optimism regarding the implementation of meditation, yoga, relaxation with imagery, and massage.
As the body of research on the efficacy of these therapies expands, hopefully the medical coverage and assistance for these therapies will also improve—making them more widely utilized modalities.
When trained, advanced practice nurses followed up written heart screening guidelines with telephone calls to survivors of childhood cancers, screening uptake more than doubled among those who received the telephone-based counseling.
It is estimated that 328,000 Americans were aged ≤20 years when their cancer was diagnosed. The pediatric cancer survival rate now approaches 80% and is rising—underscoring the need to understand and address why more survivors do not get recommended heart screenings to detect cardiomyopathy early when interventions can make the most difference.
The research, led by investigators at St. Jude Children’s Research Hospital, focused on adults whose childhood cancer treatment put them at risk for a variety of heart problems, including cardiomyopathy, which can lead to heart failure and other health problems. Survivors treated with chest irradiation and/or anthracyclinebased chemotherapy drugs are predisposed to cardiomyopathy before middle age, with the risk increasing with the cumulative dose of either therapy alone or in combination.
The study, published online November 3, 2014, in the Journal of Clinical Oncology, enrolled survivors participating in the Childhood Cancer Survivor Study (CCSS) aged ≥25 years who had received cardiotoxic therapy with no prior cardiomyopathy screening over the past 5 years (n = 472; mean age 40.1 years; range 25-59 years).
Participants were then randomized equally to receive standard care, comprised of a written survivorship care plan (SCP) that included general cancer treatment and heart health screening recommendations (n = 234; non-APN arm), or standard care with the addition of two telephone counseling sessions (n = 238) from an advanced practice nurse (APN arm).
In addition to the mailed SCP that survivors received in the non-APN arm of the study, those in the APN group received two phone calls from an APN at 1 and 3 weeks after receiving their individualized SCP in the mail; after each call, the survivor received a follow-up letter recapping the counseling session.
The researchers noted that the telephone counseling sessions were geared to address barriers to cardiomyopathy screening which survivors are known to experience (Box).
After 1 year of follow-up, 205 survivors in the APN group (52.2%) completed the primary outcome of the study (cardiomyopathy screening within 1 year), compared with 22.3% in the non-APN–counseled group. When researchers adjusted for sex, age (<30 vs ≥30 years), and the survivors’ Children’s Oncology Group–recommended risk-based screening frequency (annual, 2 years, or 5 years), survivors receiving the APN counseling were more than twice as likely to get the recommended cardiomyopathy screening versus those in the standard care– only cohort.
“This intervention offers a model for how to motivate other cancer survivors, including survivors of adult cancers, to be more proactive about their health,” said the study’s first and corresponding author Melissa M. Hudson, MD, who directs St. Jude’s Cancer Survivorship Division and co-leads its Cancer Prevention & Control Program. “This study shows that by understanding and addressing the concerns and obstacles survivors face to acting on screening recommendations, medical providers can increase the number of survivors who get this potentially life-saving test.”
Hudson and colleagues concluded that “this method of intervention provides pediatric cancer follow-up centers with a long reach to their survivor population that can be adapted to support other health-protective screening in other at-risk survivor populations.” Study authors noted that future research will assess interventions involving electronic and mobile applications which may further facilitate survivors’ interface with healthcare providers.
The addition of the GM-CSF agent sargramostim to the CTLA-4 inhibitor ipilimumab (Yervoy) prolonged overall survival (OS) and lowered toxicity for patients with unresectable stage III or IV melanoma, according to results from a phase II study published in the Journal of the American Medical Association.
Treatment with the combination of ipilimumab and sargramostim demonstrated a 1-year OS rate of 68.9% compared with 52.9% with ipilimumab monotherapy. Additionally, grade 3 or higher side effects were substantially lower with the combination. However, a significant improvement in progressionfree survival (PFS) was not seen in the study.
“This reveals the possibilities of combining an immune signaling molecule with taking the brakes off at the same time,” said first author F. Stephen Hodi, MD, the director of the Melanoma Treatment Center and director of the Center for Immuno-Oncology at the Dana-Farber Cancer Institute.
The phase II trial randomized patients with metastatic melanoma in a 1:1 ratio to ipilimumab plus sargramostim (n = 123) or ipilimumab alone (n = 122). Ipilimumab was administered at 10 mg/kg, which was determined prior to the FDA approval of ipilimumab at 3 mg/kg. The primary endpoint of the study was OS.
At a median follow-up of 13.3 months, the median OS for ipilimumab plus sargramostim was 17.5 versus 12.7 months for ipilimumab. The median PFS was 3.1 months in both arms of the study.
Patients treated with the combination experienced fewer side effects compared with singleagent ipilimumab. The rate of grade 3 or higher adverse events was 45% versus 58%, for the combination and single-agent regimens, respectively.
“The assumption at this point is that maybe GMCSF is regulating the immune system and the organs that protect us all from outside invaders, and that would be the lung and the gut,” Hodi said when he presented the data at the 2013 ASCO Annual Meeting. “And the GM-CSF probably plays a role in that microenvironment that’s different than other organs. In this case, it may play a role in keeping the immune system in check.”
In March 2011, the FDA approved ipilimumab as a single agent for the treatment of unresectable or metastatic melanoma. In the pivotal study, the OS with ipilimumab was 10 months compared with 6.4 months with a gp100 peptide vaccine (HR = 0.66; P = .0026).
Following its approval, ipilimumab continued to be explored as a single agent and in combination with the PD-1 inhibitor nivolumab in several clinical trials. In the phase I study presented at the 2014 ASCO Annual Meeting, the combination of ipilimumab and nivolumab demonstrated a 2-year OS rate of 79%, regardless of BRAF and PD-L1 status. Additionally, the durable objective response rate with the combination was 43%.
A phase III study looking at ipilimumab monotherapy in the adjuvant setting for patients with melanoma showed a statistically significant improvement in recurrence-free survival (RFS). In this study, ipilimumab was administered at 10 mg/kg. At a median follow-up of 2.7 years, RFS rates were 46.5% with ipilimumab versus 34.8% with placebo. The median RFS was 26.1 versus 17.1 months for ipilimumab and placebo, respectively.
The ongoing phase III ECOG 1609 trial is comparing two doses of ipilimumab to interferon for patients with stage III/IV melanoma. Patients will receive adjuvant ipilimumab at either 10 mg/ kg or 3 mg/kg every 21 days for 4 cycles. This will be followed by a maintenance period, utilizing the same dose administered every 90 days for 4 cycles. This study will help determine the benefits, dose, and optimal duration of treatment for ipilimumab following surgery.
Ipilimumab’s FDA approval in 2011 changed the outlook on melanoma. However, many providers have been hesitant to use ipilimumab due to the fear of its side effect profile. Immune-related adverse effects are different than those associated with chemotherapy or radiation. The use of GM-CSF with ipilimumab in this trial is associated with an increased overall survival and, more importantly, a decrease in immune-related side effects associated with ipilimumab
Yet it is important for nurses to realize that the addition of GM-CSF increases the importance of their role in education, communication, and symptom management. Patients must self-administer GM-CSF, and it is the nurse’s role to ensure that patients are comfortable and able to self-inject. This often is challenging and emotional for patients. Fear is a strong emotion in patients who have to self-administer GM-CSF. It is our role as nurses to properly educate patients.
Although GM-CSF reduces the immune-related adverse events of ipilimumab, it has its own associated side effects. Injection site reactions can occur with erythema, puritis, and/or rash. Patients often experience flulike symptoms with GM-CSF including fatigue, fever, chills, arthralgia, and nausea.
Education about adverse effects of both ipilimumab and GM-CSF is crucial to allowing for patient safe care. These side effects can affect activities of daily living, and therefore nurses must be attuned to educating patients and managing these side effects associated with GMCSF with NSAIDs, antihistamines, and other supportive measures while being vigilant to continue surveillance for ipilimumab toxicities.
Approximately one-third of cancer survivors in the US reported a financial problem or the need to modify work plans, according to the results of a large survey presented at the 2014 Palliative Care in Oncology Symposium. Women, racial/ ethnic minorities, younger survivors, and uninsured survivors were all disproportionally affected by these hardships. Abstract 238
The survey of 1592 survivors showed that 27% reported at least one financial problem, while 37% reported a work-related hardship. Cancer-related financial hardships included incurring debt, filing for bankruptcy, borrowing money, making sacrifices, and worrying about paying medical bills.
Work hardships included changing to a flexible schedule or less demanding job, extending or taking unpaid leave, not accepting a promotion, delaying retirement, and taking an early retirement.
“Cancer survivors are at increased risk of financial hardship,” said Robin Whitney, RN, BSN, lead study author, cancer survivor, and PhD student at the Betty Irene Moore School of Nursing at the University of California, Davis. “This is important not only because it can affect their quality of life, but also because individuals with more financial stress are more likely to delay or forgo needed medical care.”
This analysis focused on a subset of cancer survivors surveyed in the 2011 Medical Expenditures Panel Survey Experiences with Cancer Survivorship Supplement.
Predictors of financial burden included active treatment, age, insurance status, health, and race/ethnicity. Patients undergoing active treatment experienced 92% more difficulties (odds ratio [OR] 3.2; 95% CI, 2.1-5.0), patients under age 65 years experienced 130% more difficulties (OR 2.4; 95% CI, 1.7-3.3), and patients without insurance experienced 67% more difficulties (OR 2.4; 95% CI, 1.3-4.4).
Minorities were also disproportionally affected: nonwhite patients experienced 41% more difficulties (OR 1.6; 95% CI, 1.1-2.3) than their white counterparts.
Female patients experienced 30% more work modifications (OR 1.5; 95%, CI 1.1-2.2) than their male counterparts, though the difference was not statistically significant. Nonwhite patients experience 54% more modifications (OR 1.7; 95% CI, 1.1-2.6) that their white counterparts, whereas patients undergoing active treatment experienced 40% more work modifications than those who were at least 5 years removed from treatment (OR 2.9; 95% CI 1.7-4.9). Patients with worse health were also more likely to make a work modification, Whitney noted.
“Screening and support for these issues may be an important part of cancer care, not only during active treatment, but across the entire survivorship trajectory,” Whitney said. “Additional interventions might benefit groups who are at higher risk of having these problems, such as minorities, younger survivors, women, those without insurance, and those with worse overall health.”
This analysis was the first to examine financial hardship disparities in a nationally representative group of cancer survivors, the authors noted. Overall, 47% of survivors surveyed were younger than age 65 years, 56% were female, and 88% were white.
Eighty-nine percent of patients with cancer reported making lifestyle modifications to cope with the high costs of cancer treatment, and more than one-third altered their medical care, according to the results of a new nationwide survey, underscoring the need for oncology practitioners to screen for and anticipate potentially harmful cost-coping behavior to alleviate patient distress and promote optimal care. Abstract 161
“We need a better, more open dialog between patients and providers about the financial burden associated with cancer care costs,” said lead study author Ryan D. Nipp, MD, reporting the results at the ASCO Palliative Care in Oncology Symposium. Previous studies have suggested that the financial burden of cancer care causes substantial patient distress: approximately 13% of Americans are burdened by high out-ofpocket cancer care costs, according to the American Cancer Society, and as many as 20% report spending their life savings to pay for their care.
Of 174 patients surveyed, 78% reported spending less on leisure activities, 57% spent less on basics like food and clothing, 54% had to borrow money, and 50% of patients used their savings to pay for care. Other lifestyle adjustments which patients reported included having to sell possessions (18%) and their families having to work more (15%). For those who adjusted their medical care, 28% cited not filling prescriptions and 22% took less medication. Ten percent of those surveyed missed a test, 8% missed a procedure, and 6% missed an appointment.
Patients on the study had all stages of disease, noted Nipp, an oncology fellow at the Dana- Farber Cancer Institute. The majority (85%) had breast cancer, 4% had colorectal cancer, and 11% had other solid tumors. Notably, all of the respondents had health insurance.
patients use to cope financially, the researchers looked at certain demographic factors to help identify those patients who might be most at risk for lifestyle- or medical care–altering behaviors. They found that patients under age 65 years and those earning less than $20,000 annually were more likely to alter their medical care, whereas patients who were younger, had more education, and had a shorter duration of chemotherapy were more likely to make lifestyle adjustments.
“We found that most participants altered their lifestyle more than their medical care, but a significant proportion alter their care, which may jeopardize their health,” said Nipp. “With this study, we can help identify certain types of patients who may be at risk for altering their medical care or their lifestyle and at least engage in conversations with these patients,” about their choices and develop screening tools and interventions to ease the burden—a focus of future research.
At the 2014 Multidisciplinary Symposium in Thoracic Oncology in Chicago, Jyoti D. Patel, MD, associate professor in Medicine- Hematology/Oncology at the Feinberg School of Medicine at Northwestern University, led a breakout session on how to manage the toxicities associated with the molecular therapies used to treat patients with lung cancers.
The nuances of providing this care effectively can be complex but Patel’s premise was simple: addressing toxicities promptly is vital because the treatment regimens used for lung cancer require tight compliance. “We hope our patients will be taking these medications for a year or more. They must be willing to take them every day,” she said. “But when toxicities are severe, the effects can interfere with activities of daily living and when that happens, treatment adherence can be drastically affected.”
Though the care of lung cancer patients requires specific expertise in oncology that takes years to develop, Patel suggested that colleagues remember their earliest days as physicians, too. “We need to put on our internal medicine hats again,” she said. “That means being proactive to counsel and educate our patients ourselves.”
Patel’s practice relies heavily on toxicity appointments with a physician, not a midlevel provider, to maintain patient compliance. The physician reviews each patient’s symptoms, toxicities, and medication adherence: “That’s when we might cover anecdotal points like limiting hot water exposure, using a humidifier, or choosing a thick, oil-based skin cream [versus a water-based lotion] to help with rashes.” The intent is to discover and address toxicities before treatment adherence is affected. Dosing, of course, may need to be adjusted and can also be done at this appointment.
Patel reviewed EGFR inhibitor–associated toxicity in erlotinib, afatinib, and cetuximab. She noted that papulopustular rash and diarrhea are their most common side effects. With severe skin cracking and fissures, her practice recommends brief bleach soaks to prevent infection, zinc creams and, for heels and fingertips, silver nitrate, zinc oxide, and cyanoacrylate glue (skin glue or Krazy Glue).
Crizotinib, found to be active against ALK, MET, and ROS1, can cause GI upsets within 2 to 5 days of starting treatment. It can also cause visual effects at 2 weeks; both these side effects typically resolve on their own. Crizotinib can also cause peripheral edema at 2 to 3 months, which generally does not resolve on its own. Rare but serious toxicities include pneumonitis and neutropenia.
Patel also discussed crizotinib’s potential to cause hypogonadism, noting that testosterone levels may drop to levels that affect patient quality of life within weeks. She urged colleagues to monitor testosterone levels in all male patients on crizotinib and to refer them for endocrine care as appropriate.
She also addressed crizotinib’s tendency to cause bradycardia, noting that 11% of patients in trials experienced this adverse effect (AE). Patel recommended discontinuing crizotinib until the patient’s heart rate returns to 60 beats per minute or greater. Also, be prepared to adjust or discontinue other medications as needed, as well as to adjust the crizotinib dose itself, she advised.
Finally, Patel discussed ceritinib. “In studies, nearly 60% of patients needed a dose reduction to be able to continue with it,” she said. “When we start patients on ceritinib, we really need to see them every week initially.”
Given that 10% of patients needed to discontinue ceritinib due to AEs [mainly pneumonia, pneumonitis, and decreased appetite], she advised colleagues to monitor patients’ liver function tests at least monthly and reduce their doses as soon as toxicities emerge.
To close, Patel reminded colleagues that these toxicities are often insidious and usually don’t correlate with laboratory findings and, to return to her internal medicine analogy, require frequent referrals across multiple disciplines.
“In general, lung cancer patients are very motivated to take the drugs we prescribe,” she said. “Unfortunately, they may not be able to if we can’t manage the associated toxicities.”
When facing the fear and anxiety of having chemotherapy, my lung cancer patients often ask if their chemo could be taken orally. No long days in the infusion room watching the IV drip, no seemingly endless needle sticks to start an IV, no continuous oncologist appointments, no problem . . . or is it?
The development of oral chemotherapy agents has been well received by clinicians and patients alike. However, consistent patient education is paramount when oral chemotherapy is prescribed for the patient to receive the medication’s maximum benefit. Information regarding skipped doses, missed doses, blood work, side effects and follow-up appointments should be included in the patient’s education.
Well-orchestrated education originating with the physician and then echoed consistently with the clinical staff helps to reinforce the message that chemotherapy, even though taken orally, can have potential life-threatening ramifications if not taken properly.