In the middle of Breast Cancer Awareness month, First Lady Jill Biden visited Miami, Florida, where I am based, to spotlight President Biden’s Cancer Moonshot initiative, which is designed to combat and end cancer. Biden and US Senator Debbie Wasserman Schulz, who is a breast cancer survivor, visited Sylvester Comprehensive Cancer Center for an event to spotlight the Moonshot initiative, Breast Cancer Awareness Month, and National Mammography week.

This month has been a revelation in terms of breast cancer awareness. Katie Couric, noted broadcast journalist, has once again shone the spotlight on a potentially lethal cancer. The University of Michigan coined the term “the Couric Effect” in the year 2000 when she advocated for colonoscopy screening after her husband from colon cancer in his 40s.

 There was a national jump in colonoscopy screening rates that year by approximately 20%. The same phenomena may be in the process of happening again.

Couric was in the middle of filming her 3D mammogram and ultrasound when her physician spotted a suspicious area. The camera was turned off. Katie found out that she needed a biopsy and then was given the diagnosis of stage IA HER2-negative breast cancer. She had a lumpectomy and 15 radiation therapy treatments this past summer. She received her diagnosis on June 21; on July 14 she had surgery, and on September 7, she began her first of 15 sessions of radiotion. Couric has shared that for the next 5 years she will be taking an oral aromataste inhibitor in order to decrease her estrogen level.

In addition to sharing various detrails about her diagnosis and treatment plan, Couric has also shared that she has dense breasts and that her diagnosis required a breast ultrasound. On TV, she has stressed the importance of this 2-step process. During an appearance at the TODAY show where she was a co-anchor for many years, Couric noted that only 70% of women who meet criteria for breast cancer screening complete this important step. The COVID-19 pandemic had an impact on women going for screening as well. Couric herself did not go for these annual tests since December 2020. In her personal blog, she wrote that the pandemic may have skewed her sense of time.

In addition to advocating for annual mammograms, Couric is educating the public about dense breasts and the importance of ultrasounds. Approximately 40% to 50% of women between the ages of 40 years to 74 years have dense breasts.

 Couric, at 65, also falls into this category.4 Patients with dense breasts may be at increased risk of developing breast cancer and it is recommended that they get routine mammaorgrams similar to other individuals. However, women with dense breasts may also benefit or a 3D mmammogram, or an ultrasound, as these screening devices may be able to better detect tumors in this population. There is also a new modality called SoftVue, which is a new form of ultrasound. It has received FDA approval and, when coupled with mammography, increases detection accuracy by approximately 20%.

Currently, 38 states, including Florida, New York, California, and New Jersey, as well as the District of Columbia have a requirement for “some level of breast density notification after a mammogram.”

 A federal national standard for reporting dense breast findings to women does not exist at the present time. Since 2019, there have been efforts for legislation on a federal level. In addition, the FDA has been trying to push for a standard covering reporting these findings.

I personally believe that there is a benefit to additional screenings for this patient population. I hope standard guidelines emerge in the coming years, and I believe that Katie Couric’s advocacy may be the incentive needed to get us there.

Last call for 10.11.22-A prime-time read of what's going down in Florida politics. Florida Politics. October 11, 2022.October 14, 2022. https://bit.ly/3EQ0AeS

Berman M. Katie Couric's Breast Cancer. MEDPAGE today. October 6, 2022. Accessed October 12, 2022. 

Weisholtz, D. TODAY. Exclusive; Katie Couric on telling daughters she has breast cancer: 'Hard to deliver that news'. October 3, 2022. Accessed October 12, 2022. https://on.today.com/3MOpyx1

Uda, R. Do you have dense breasts? Here's how to find out-and what to know about the cancer risks. Katie Couric Media. October 14, 2022. October 11, 2022. https://bit.ly/3So4ezS

State legislation map. Dense Breast Info. Accessed October 13, 2022. 

Articles

Katie Couric is educating the public about the importance of ultrasounds for women with dense breasts.

Opinion: The Couric Effect May Be Just What the Breast Cancer Community Needs

Often, patients who have just had chemotherapy, or may be in the middle of treatment, are admitted to oncology units or general medical-surgical hospital floors. Computerized admission programs usually contain questions dealing with appetite and weight loss not attributed to diet, because according to the National Cancer Institute (NCI), 30% to 85% of 

patients with cancer experience poor nutrition

The loss of lean body mass, known as sarcopenia, is cited by the NCI as an independent variable for the cancer patient having a less than favorable prognosis.

Some factors that aggravate a cancer patient’s inadequate intake of food are nausea and vomiting, differences in taste and smell, and trouble swallowing. The classic adverse event, constipation from the opioids often prescribed to control pain, is well known.

Antibiotics may cause diarrhea and malabsorption of nutrients, too. Being in an unfamiliar environment with constant interruptions when you want to eat can also aggravate underlying depression and worsen anxiety related to the diagnosis. 

Once a patient has said they are experiencing weight loss or are not getting enough food, what can you as the nurse do, besides documenting it in their file, to prevent the slide into future nutrition problems?

 If you are doing the admission, this may come up as an auto generated consult that the nurse can submit without calling the physician. In some facilities, the nurse can order the consult even if it is not auto generated. If you work in the middle of the night and get an admission, the dietician can hopefully see the patient before lunch depending on the acuity of the setting.

 Having family members or caregivers bring in the patient’s favorite food from a restaurant is fine unless doctors’ orders say otherwise. However, really finding out what patients like to eat at home is even better. Sometimes culture dictates what we like. In culturally diverse cities like Miami, New York, and Los Angeles, rice is often a staple at every meal.

 Many hospital kitchens have food available in the refrigerator, like turkey or tuna sandwiches with cheese, as well as graham crackers, and apple sauce. Doesn’t sound like a lot, but if the patient is nauseous it might fill in the gaps between meals. According to the American Cancer Society (ACS), eating several times a day instead of 3 meals a day is suggested as a way of 

 Look at the Medication Administration Record (MAR) and see if the patient is on an anti-emetic medication. Most of the time this is ordered on admission. Ask the patient if this has helped in the past. If that is the case, administer the drug before meals.

 Suggest that the patient make food a priority by deciding to eat what they want, when they want. If they want to eat breakfast food at night, that’s fine. The ACS stresses eating preferred food whenever patients are in the frame of mind to indulge.

 In other words, if French toast is what they want at 6 pm, great. Also, eating in a nice environment, or eating with family or friends can improve appetite. Even a hospital room can be transformed into a patient oasis with pleasant company.

 Cancer patients may need to keep their caloric intake high to make up for weight loss. Boost or Ensure are two popular over-the-counter meal replacement shakes. These shakes even come in easy to pour plastic bottles, no need to flip the top open as in the original container years ago. They may mean the difference between consuming sufficient calories versus having a caloric deficit. Don't forget that if the patient has a temperature they will lose moisture when the fever breaks. Taking in extra fluid could make up for this water loss.  

Protein bars are a controversial subject, since they may be loaded with sugar that just give the patient empty calories and may raise their glucose levels. This may not be advised for a patient with cancer who has a comorbidity of diabetes. A better solution might be peanut butter, crackers, or even low fat/low sugar Greek yogurt under 30 grams of sugar for an 8 ounce serving.

 If a patient does want to try a protein bar, the best recommendation would be to have them check with their oncologist first. 

National Cancer Institute.  National Cancer Institute website. Basic principles of nutrition in patients with cancer. Published 2018. 

https://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq

American Cancer Society. Managing eating problems caused by surgery, radiation, and chemotherapy. American Cancer Society website. Published 2018. 

https://www.cancer.org/treatment/survivorship-during-and-after-treatment/staying-active/nutrition/nutrition-during-treatment/poor-appetite.html

American Cancer Society. Snacks and dashboard dining. American Cancer Society website. 

https://www.cancer.org/healthy/eat-healthy-get-active/take-control-your-weight/snacks-and-dashboard-dining.html

What can nurses do to prevent patients from experiencing nutrition problems due to loss of appetite?

Debi Fischer, RN, LCSW

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