A cancer diagnosis can be nerve-wracking enough, but sitting in the waiting room anticipating chemotherapy treatment can make anxiety even worse.

A nurse-led intervention was recently implemented at the SUNY Upstate Medical University, in Syracuse, NY, to decrease wait times and the length of inpatient stays, as well as lessen the amount of anxiety patients were feeling before getting treatment.

“According to the Centers for Disease Control, 65,000 patients will undergo chemotherapy – some of these patients requiring inpatient treatment,” said Kristin Soper, MS, RN, ANP-BC, AOCNP, while presenting her findings at the 45th Annual ONS Congress. “Patients electively admitted for chemotherapy tend to have long wait times associated with their treatment.”

Soper implemented a complete redesign of the elective chemotherapy program. The following changes were instated:

Patients had to have lab results, treatment plans signed, and all necessary testing and central access obtained before being admitted

Chemotherapy wait times were measured using the electronic medical record (EMR)

Staff were educated on the urgency of chemotherapy, as well as the benefits of reducing treatment-related wait times

The following were measured to determine success of the program: time of admission, RN release of orders, pharmacy verification, and time of infusing chemotherapy.

Ultimately, wait times decreased by 41%, “and in doing so, length of stay was found to be less impacted than expected,” Soper said, explaining that this may be a result of patients being scheduled for treatment late in the day.

“Satisfaction and anxiety were measured quantitatively with results suggesting that decreasing wait times did improve both anxiety and satisfaction,” Soper said. Additionally, qualitative results showed that shorter wait times led patients to feel that their time was more respected, and the process was more efficient and seamless.

Shorter wait and stay times not only improve patient satisfaction but can also result in cost savings for the hospital.

“Nurses could be leaders in this project to help ensure that care provided is patient-centered,” Soper said. “The focus on cost savings could be monumental to guide other nurse-led initiatives.”

Soper K. Workflow redesign of the elective chemotherapy program to reduce wait times associated with chemotherapy. Presented at: 46th Annual ONS Congress. April 20, 22, 27, 29, 2021. Virtual

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An intervention to decrease chemotherapy wait times led to better patient satisfaction and reduced anxiety. 

Reduce Chemo Wait Times and Improve Patient Satisfaction

Oncology nurses are responsible for educating patients and caregivers on central venous catheter (CVC) usage after bone marrow transplant, but in the wake of the COVID-19 pandemic, in-person classes were restricted.

So, a team at the Wayne State University Barbara Ann Karmanos Cancer Institute created patient education videos to enhance the skills and improve confidence in patients and caregivers performing CVC care.

“The need for the video actually became imperative in March 2020 when the COVID-19 pandemic struck. What we have traditionally done for our bone marrow transplant patients that will be going home with their central venous catheters still inserted is instruct their caregivers how to safely and effectively take care of it. When the pandemic struck, visitor restrictions prohibited [these] classes,” said Denise Henderson, Med, BSN, RN, OCN.

Henderson presented her team’s process during a poster presentation at the 46th Annual ONS Congress. She said that the project started before the pandemic, when the most frequently asked question by patients and caregivers in the class was, “Is there a video for this?”

Once COVID-19 swept the nation, the nurses realized how important video instructions would be.

Nurses served as producers, voice over recorders, script writers, and onscreen talent, while the hospital’s media specialist did pre-/post-production, editing, and graphics. The result was a 7-minute video called “Taking Care of Your Central Venous Catheter.”

The video helped to ease patient and caregiver apprehension when it came to the complex skills of CVC care. At the time of the poster publication, “Taking Care of Your Central Venous Catheter” had more than 300 views on YouTube.

As the hospital’s visitor policy begins to loosen, oncology nurses are still using the video to help educate patients and caregivers.

“We use this now in adjunct [to in-person education], as caregivers are slowly allowed back in the institution,” Henderson said. “They still say, ‘is there a video?’ and because of the process that we put in place to get the video done, we can now say yes.”

Henderson D, Beaver C, Mitchell J, Cook S. Developing Effective Patient Education Videos, From a Not So Simple Process to Implementation. Presented at: 46th Annual ONS Congress. April 20, 22, 27, 29, 2021. Virtual

When in-person classes on central venous catheter care were limited due to the COVID-19 pandemic, educational videos became even more important. 

‘Is There a Video for That?’ Caregiver Education Video Boosts Confidence

The Food and Drug Administration (FDA) granted an accelerated approval to pembrolizumab (Keytruda) plus trastuzumab, fluoropyrimidine- and platinum-containing chemotherapy for the frontline treatment of patients with locally advanced unresectable or metastatic HER2-positive gastric or gastroesophageal junction (GEJ) adenocarcinoma.

The approval was based on interim findings from the ongoing multicenter, randomized, double-blind, placebo-controlled KEYNOTE-811 trial. The trial included 264 patients with HER2-positive advanced gastric or GEJ adenocarcinoma who had not previously received systemic therapy for metastatic disease. Half the patients received 200 mg of pembrolizumab every 3 weeks in combination with trastuzumab and either fluorouracil plus cisplatin or capecitabine plus oxaliplatin.

The overall response rate, as assessed by a blinded independent review committee, was 74% in the pembrolizumab arm, and 52% in the placebo arm. Average duration of response was 10.6 months (range 1.1 months to 16.5 months) for the immunotherapy agent, compared with 9.5 months (range, 1.4 months to 15.4 months) for the placebo arm.

Researchers said that the adverse event profile observed in KEYNOTE-811 is consistent with the known safety profile of the drug.

The recommended dosing for this patient population is 200 mg of pembrolizumab every 3 weeks or 400 mg every 6 weeks.

FDA. FDA grants accelerated approval to pembrolizumab for HER2-postive gastric cancer. May 5, 2021. 

https://www.fda.gov/drugs/drug-approvals-and-databases/fda-grants-accelerated-approval-pembrolizumab-her2-positive-gastric-cancer?utm_medium=email&utm_source=govdelivery

The FDA granted an accelerated approval to pembrolizumab plus trastuzumab, fluoropyrimidine- and platinum-containing chemotherapy for the frontline treatment of patients with locally advanced unresectable or metastatic HER2-positive gastric or gastroesophageal junction adenocarcinoma. 

FDA Approves Frontline Pembrolizumab for HER2+ Gastric, GEJ Cancer

Ethical dilemmas are unavoidable when caring for patients with cancer, and oncology nurses are often tasked with resolving such issues, relying on professional codes and standards to help guide what is best for the patient.

“One thing about ethical issues is that there’s usually not a right or a wrong. We’ve always tried to go for the best solution for the patient and the family, as well as the care team in the situation,” said Joyce Neumann, PhD, APRN, AOCN, BMTCN, FAAN, an advanced practiced registered nurse and adjuvant ethicist at The University of Texas MD Anderson Cancer Center. Neumann recently led a presentation on ethical dilemmas in oncology nursing at the 46th Annual ONS Congress.

While end-of-life care can highlight ethical dilemmas, the challenges actually start at diagnosis, when nurses are faced with educating patients and their family members, determining goals of care, discussing clinical trial participation, and assessing patients physically, cognitively, and psychologically.

Then comes the informed consent process, preparing for possible outcomes of treatment, establishing advanced care planning and goals of care – both through treatment and potentially at the end of life.

For example, nurses may need to balance being positive and providing hope with providing realistic information and expectations to patients and their loved ones.

Neumann explained that there were 669 ethics consults at MD Anderson between September 2015 and August 2020; 29% were filed by nurses. The most common reasons for these requests were inquiring about the appropriate levels of treatment.

“Probably the most major ethical challenge that we come to is when is enough enough, and when do we transition patients from curative or aggressive care to comfort care?” Neumann said.

One major way to address these ethical dilemmas in cancer care is to promote advanced care planning – where patients’ wishes, delegation of medical decision maker, and more are clearly documented for the patient, family, and clinical staff members.

Nurses should also consider patients’ comorbidities, prognosis, religious or spiritual views, and goals to help guide the best possible care.

“We obviously need to know patient preference – I can’t stress that enough,” Neumann said. “Does the patient have capacity for their decisions and those type of questions on quality of life? What does that mean to the patient? … If the patient does not have the capacity, can the family explain to us what conversations they’ve had with the patient prior to treatment starting, [regarding] views of care?”

Knowing your patient’s beliefs and goals is key to providing ethical cancer care.

Expert Talks Ethics in Oncology Nursing

Oncology nurse practitioners are a crucial population in the healthcare arena. In an attempt to usher more nurses into the oncology NP career path, City of Hope teamed up with Azusa Pacific University School of Nursing to create the Oncology Nurse Practitioner Fellowship.

The results of the program were evaluated in a presentation at the 46th Annual Oncology Nursing Society Annual Congress.

“The role of the oncology [advanced practice provider] requires extensive training and education in a specialized area practice,” said Katherine Butcher, NP, MSN, a nurse practitioner at City of Hope who recently completed the program.

Of note, many states have given full practice authority to nurse practitioners, and 

 that this become the norm across the nation.

The fellowship consisted of 12 months of clinical rotations as well as 3 semesters of coursework and learning opportunities. It allowed fellows to collaborate with experts in important oncology specialties, such as genomics, infectious disease, palliative care, hematology, medical oncology, and survivorship. Individuals who were accepted into and enrolled into the fellowship program could also enroll in Azusa Pacific University’s Doctorate of Nursing Practice program.

“The exposure and collaboration with clinical experts in each specialty provided an experience and a wealth of knowledge that I will carry into my career moving forward,” Butcher said. “Participation in this fellowship has direct implications on the improvement of nursing practice, investing the education of APPs.”

Fellows were expected to reach a number of milestones that would not only help evaluate the program, but also promote their growth as a provider. They included:

Clinical rotations in hematology, medical oncology, supportive medicine, and the department of medicine

Obtaining an ASCO Advanced Practitioner Certificate

Presentation at a local or national conference

Graduation from Azusa Pacific University’s Post-Masters ONP Certificate program

“It is well known that the number of individuals with cancer and cancer survivors continues to grow. And with this growth, advanced practice providers are relied upon to ensure that patients receive high-quality care,” Butcher said.

Butcher K. Oncology Nurse Practitioner Fellowship: A Reflection on the Educational Benefits of a Postdoctoral Fellowship Program. Presented at: 46th Annual ONS Congress. April 20, 22, 27, 29, 2021. Virtual.

Nurse practitioners are more valuable than ever in the world of cancer care.

NP Fellowship Helps Prepare Providers for Oncology Career

It is well known that fear of recurrence is a major issue in the cancer community, but can genetic test results outlining risk impact those feelings?

For this episode of “The Vitals,” we spoke with Maurade Gormley, CPNP, RN, assistant professor and post-doctoral fellow at the NYU Rory Myers College of Nursing. Her recent research analyzed how Oncotype DX genomic test results may increase fear of recurrence in breast cancer survivors.

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Genetic Testing May Increase Fear of Recurrence

The COVID-19 pandemic has added significant challenges to individuals who are hearing impaired – about 15% of the American population, and a third (33%) of the population over the age of 65 – as mask mandates make it so that they can no longer rely on lip-reading.

“Hearing-impaired patients have reported frustration, isolation, and fear as a result of being unable to understand and communicate with their providers in hospital settings. In addition, impaired patient-caregiver communication is a safety issue, as patients with communication barriers are 3 times more likely than those without to experience adverse events in acute care settings,” Brianna DiTullio, RN, BSN, a nurse at Memorial Sloan Kettering Cancer Center said.

DiTullio’s research, which was presented at the 46th Annual Oncology Nursing Society Congress, found that clear face masks can decrease these communication barriers and increase trust between clinicians and patients with cancer who are hearing impaired.

She was originally inspired to conduct this research when a partially deaf patient – she called him John – was at MSK’s bone marrow transplant unit in 2019. He was immunocompromised and on neutropenia precautions, so everyone in his room had to wear a mask.

“Given that lip reading is impossible to do through a traditional face mask, he essentially lost his ability to communicate every day during rounds with the transplant team,” DiTullio said. “I would watch him nod his head along with the conversation as 5 or 6 masked doctors talked to him about his symptoms and his plan of care. But as soon as the team left, he would admit that they didn’t really understand most of what was being said.”

The pilot project involved 6 patients who were hearing impaired and 12 staff members (nurses, patient care technicians, doctors, occupational and physical therapists) who used clear face masks over a 2-day trial period. Ultimately, there was a major difference in patient understanding and trust as a result of the clear masks.

Before the clear masks, 67% of patients reported that they often have difficulty understanding what staff is saying through the masks, and 33% said that they almost always face this issue. After the new masks were implemented, a third (33%) of patients said that they never have issues understanding what staff is telling them. Seventeen percent reported rarely facing this issue, 17% reported sometimes facing it, and 33% reported often facing it.

The clear masks also increased the amount of communication between patients and their providers. At baseline, 50% of patients reported that they almost always have conversations with hospital staff while they are wearing masks, and after the clear masks were implemented, this number increased to 83%, with the rest of participants (17%) reporting that they often have conversations with hospital staff.

“Anecdotally, patients loved that they could now see the faces of the staff caring for them, point out that they could now see their smiles,” DiTullio said.

Finally, the clear masks improved trust between patients and providers. Before they were implemented, 34% of participants said that they were neutral/unsure of their trust levels for hospital staff, 33% were trusting, and 33% were extremely trusting. After 2 days with clear masks, 67% of participants said that they were extremely trusting of the staff, and 33% said that they were trusting. Of note, after the clear masks were used, no patients reported being neutral/unsure.

DiTullio recommended that hospitals invest in clear face masks to better communicate with this patient population.

“While this project was originally carried out in a pre-COVID-19 setting, it now has much more far-reaching implications,” DiTullio said. “Health facilities have a responsibility o accommodate the specialized needs of patient populations they care for, just like how they provide interpreter services for non-English—speaking patients. The hearing-impaired population nis no different.”

DiTullio B. Clear-faced masks for hearing-impaired patients. Presented at: 46th Annual ONS Annual Congress. April 20, 22, 27, 29, 2021.

When patients rely on lip-reading to communicate, mask mandates have major effects on their care. 

Clear Masks Improve Care, Build Trust for Hearing-Impaired Patients

Providing end-of-life care for patients with cancer can be both rewarding and challenging for oncology nurses. A multidisciplinary approach is crucial to ensuring high-quality care and mitigating work-related stressors for clinicians working in hospice.

“The demand for hospice services for patients requiring professional supportive care at the end of life for chronic, life-limiting conditions such as cancer has grown substantively in the current health care environment,” said Rebecca H. Lehto, PhD, RN, FAAN, associate professor at the Michigan State University College of Nursing.

“Despite the role of the interdisciplinary team and the need for interprofessional engagement, few studies have engaged a team methodology to elicit hospice workers perspectives of the work environment,” she added.

Lehto and her colleagues recently interviewed clinicians who work in end-of-life care to better understand their perceptions on the job.

Findings, which were presented at the 46th Annual Oncology Nursing Society Congress, showed that benefits of working in end-of-life care included making meaningful differences in the lives of patients and their families; receiving positive feedback; and teamwork.

However, that did not mean that careers in this environment were not without issues. Commonly reported stressors included:

Clinicians who were interviewed experienced “episodic, short-lived burnout,” but were taking steps to alleviate those feelings. Lehto also explained that strategies must be put in place to support the needs for these health care workers.

“At an organizational level, a multi-pronged approach that includes both personal and occupational strategies is needed to support hospice professionals across disciplines and for mitigating perceived stressors associated with this essential work.”

Lehto RH, Heeteer C, Forman J, et al. Work-related Stressors Impacting End of Life Care in Hospice: A Focus Group Study. Presented at: Oncology Nursing Society 46th Annual Congress. April 20, 22, 27, 29, 2021.

A recent study analyzed the benefits and work-related stressors of end-of-life care. 

End-of-Life Care Poses Pros and Cons for Clinicians

Genomic test results – especially if they indicate higher risk – may increase breast cancer survivors’ fear of recurrence, according to recent research.

Nurses should be aware of these findings, as well as other indicators of fear of recurrence, said study author Maurade Gormley, CPNP, RN, assistant professor and faculty fellow at the NYU Rory Myers College of Nursing. Gormley, who is also a post-doctoral fellow, recently discussed her research in an interview with 

 Can you talk about your research on fear of recurrence regarding cancer genetics, and why this is an important topic?

 Fear of cancer recurrence is one of the greatest unmet needs among breast cancer survivors and things like health care provider visits or going in for a mammography can certainly trigger a fear of cancer recurrence. But we don't know how women or other survivors respond to genomic testing that tells them a factual risk of recurrence. So that was a gap in the literature that I thought to learn more about.

The Oncotype DX test can be very helpful in terms of helping women avoid unnecessary chemotherapy or recommending chemotherapy for women who might not be indicated to receive it based on clinical factors alone. So it's very helpful in that regard, but you are telling women objective risk. How are women responding to that? Is that something that's very helpful for them to know? Or is it something that's triggering a lot of fear. And so essentially, I recruited 110 breast cancer survivors, and they answer questionnaires about their fear, their health-related quality of life distress, their illness representation, and their perceived risk.

Oncotype DX puts risk into low-, intermediate-, and high-risk categories. Women who are in the high-risk category, which means that they need to have chemotherapy in conjunction with endocrine therapy, had higher fear compared to women in the low-risk category. And women in the low-risk category only need to have endocrine therapy; chemotherapy does not provide any additional benefit to them. So that really tells us that a higher objective, recurrent score or risk of recurrence is associated with higher fear.

But then we did a regression analysis. And based on that, we were able to determine that it was actually anxiety, and certain types of illness representations that were the best predictors of fear. So for instance, women's perceived consequences of their breast cancer diagnosis [including worries like] this will have major consequences in my life; financial implications; or it will have implications to my family [and] affect other people in my life, and then also the degree of emotional upset from the diagnosis of cancer. So, it causing anxiety, anger, uncertainty, all of those things, were actually the best predictors of whether a woman would have higher fear or not.

What are the practice implications that oncology nurses should take away from these findings?

What's important for oncology nurses and other health care providers to know is that for women, receiving the Oncotype DX test or any other genomic tests predicting risk of recurrence, they need to make sure that the women are correctly understanding the test results. The population that I recruited, did have a high level of education income and was primarily White. So this does need to be assessed in the context of health literacy.

The best we can do for now is make sure that women are understanding the test results from the Oncotype DX test. And then the other thing to remember is that women with a higher score may have higher fear, but not necessarily, so every patient is going to be different. There were women in the study that had a low risk of recurrence, but very high fear. And there were women in the study who had a very high risk of recurrence, but low fear.

There are brief screening measures that can be done, that should be done and just being on the lookout for things like illness representation. So you know, women coming in and saying that this breast cancer, they're worried that it's going to have the severe consequences on their life, or they've been feeling very anxious about it very uncertain, those should be red flags to a patient that would be at high risk of developing fear of cancer recurrence, because your cancer recurrence is associated with a lot of other psychosocial sequelae, which is what we found in the study, and, and is consistent with the literature. So, it's associated with things like poor health related quality of life, distress, anxiety, depression, greater perceived risk, so it is really important to assess. And unfortunately, these symptoms emerge often in the survivorship period, because you're in this acute phase, when you're receiving treatment, you're so focused on that. And then when you know, leave your treatment, you're not in as structured of a system where you're seeing your providers regularly. And so that's when a lot of these psychosocial sequelae, and these fears can emerge.

Breast cancer survivors may experience an increase in fear of recurrence after undergoing genomic testing that reveals risk. 

Genomic Testing May Increase Fear of Recurrence

Much of oncology nurses’ work involves dealing with their patients’ quality of life (QOL), but it is also important for these clinicians to address their own QOL – especially when it comes to issues such as compassion fatigue.

Recent research presented at the 46th Annual Oncology Nursing Society Annual Congress analyzed the Professional QOL (ProQOL) tool that is currently used to better understand nurses’ QOL, compared with the Theory of Oncology Nurses’ Professional QOL.

“[QOL is] really important in helping address patient outcomes, retain oncology nurses – or nurses in general – and improve and maintain our nursing model,” said study co-author Rebecca L. Boni, PhD, RN, ACCNS-AG, OCN, assistant professor at Oakland University, while presenting the findings.

The ProQOL Scale is a 30-question survey that includes 3 subscales: burnout, secondary traumatic stress, and compassion satisfaction. To date, there have been inconsistent findings about nurses’ professional QOL compared to ProQOL findings.

“When we look at the nursing professional quality of life, the literature almost always uses the ProQOL scale,” Boni said. “It was developed for social workers, but it’s used broadly in just about all caring professions: chaplains, teachers, physicians, nurses, social workers, [it’s] all over the board… The problem is, when I looked at the body of literature, there’s a lot of inconsistent findings, whether I look at just nurses or oncology nurses.”

The researchers surveyed 14 oncology nurses from 10 different health systems. Participants were asked to rate their own QOL on a scale of 1 through 10, and complete the ProQOL. Descriptive statistics, which were then used to compare ProQOL scores and qualitative results and self-ratings.

Among the ProQOL items, 26.7% were not related from categories that emerged from the qualitative data reported by the nurses. Additionally, more than half (8 out of 13) of the sub-categories from the study were not addressed within the ProQOL, including:

Embracing complex relationships with time

Ultimately, this study found that the Theory of Oncology Nurses’ Professional QOL is likely a more precise measure of oncology nurses’ QOL than ProQOL.

“If we can better measure professional quality of life and get more consistent research that we can trust, [we can] really develop interventions that can improve professional quality of life,” Boni said. “And from there, we can improve the wellbeing of nurses, improve our patient outcomes, and stabilize the nursing workforce – all of which we know are high priorities.”

Boni RL, Dingley C. Oncology Nurses’ Professional Quality of Life: An Analysis of Defining and Measuring Professional QOL. Presented at: the 46th Annual ONS Congress; April 22, 2021; virtual.

The current scale often used to measure nurse quality of life may be missing some key factors, according to recent research. 

Brielle Benyon