Quite simply, there is no good or harm-free exemplar of smoking. Tobacco use entails embarking on a slow course of ruining your life, which is why I am vigilant when it comes to the subject. My father and husband died from cancer caused by long-term tobacco exposure. It is also impossible for me to count how many patients I have cared for over the years who have voiced their regrets for trying that first cigarette.

A disclaimer is in order here. I have never smoked. In 8th grade, we were shown a movie about the dangers of tobacco, which included a graphic picture of blackened lungs that scared me. I went home and made a plea to my parents who both smoked, to stop. For most, however, it is not that simple. Nicotine addiction is extremely difficult to overcome.

Now we have a new tobacco-related epidemic on our hands: vaping. The old record from decades ago about the absence of harm from tobacco has been dusted off and replayed,

but the target for current marketing efforts is different. Children, mostly teenagers, are the focus. The deceit has been so significant that in September of this year, the FDA threatened sanctions against Juul Labs, a major producer of vaping products, for erroneous and misleading marketing to children and teenagers about the “less harmful” nature of e-cigarettes.

Electronic nicotine delivery systems (ENDS) are designed to aerosolize liquids for inhalation. These devices include e-cigarettes, vaporizers, hookah pens, and tank systems, predominantly used to inhale nicotine and cannabis-based compounds. E-cigarettes entered the US market around 2007, and since 2014, they have been the most commonly used tobacco products among youths nationally.

By 2018, there were 288 models of ENDS on the market and more than 15,500 flavors, referred to as juices.4 Vaping behaviors also escalated considerably in high school students between 2017 and 2018.5 An extensive review of monitoring results of over 43,000 students in 8th, 10th, and 12th grades between 2017 and 2018 revealed vaping-related incidences more than doubled in each of these 3 grades. In 2019 alone, the prevalence of vaping in the 30 days before student survey completion was more than 1 in 4 students in 12th grade, more than 1 in 5 in the 10th grade, and more than 1 in 11 in the 8th grade.

 The range of flavor options and the perceptions that vaping is relatively healthy and more socially acceptable than tobacco are considered to be the major drivers in this dramatic increase in use.

As vaping continues to become a widespread issue, many are concerned with its connection to pulmonary diseases. Researchers studied the clinical courses of 53 patients who

were identified in acute-onset pulmonary disease clusters in Wisconsin and Illinois.

Fifty patients were hospitalized, 32% of whom required intubation and mechanical ventilation; 1 death was reported. The median age of these patients was 19 years. All reported e-cigarette device used before the onset of symptoms, the majority of which (84%) inhaled tetrahydrocannabinol products.

Several recent reports detailing biopsy and radiological findings are of particular interest to researchers and public health officials. The acute lung injuries associated with vaping

were primarily identified as hypersensitivity pneumonitis, diffuse alveolar hemorrhage, and histopathologic variations of pneumonia.

 The causes remain speculative, but potential etiologies cited include the aerosolization of flavoring compounds, adulteration of devices with tetrahydrocannabinol-based oils or vitamin E, and use of black market vaping products.

The most recent report of a negative vaping corollary was the development of lung and bladder primary cancers in an animal model where short-term (12 weeks) e-cigarette smoke exposure in mice was associated with the presentation of these malignancies.

The United States needs to set a global example for the prevention of ENDS-related illnesses. To do this, 4 phenomena must be addressed:

1. The young age of ENDS users is of utmost concern. Continuous, unconstrained use of ENDS in this demographic represents the first generation

of teenagers in the modern world to be allowed to put their health and longevity at risk, unchecked, with alleged long- term negative corollaries.

2. The addictive nature of nicotine, especially in young individuals, cannot be ignored. Efforts to protect youth from using nicotine during adolescence is imperative. The developing brain is particularly susceptible to permanent changes from nicotine use.

 Results of epidemiological studies have also shown that smoking in this age group is a first step toward heroin and cocaine addiction.

 Chemical changes in dopamine-receiving neurons induced by nicotine are likely to disrupt the brain’s normal reward circuitry and prime the brain for enhanced sensitivity to potentially abusive substances.

3. Vaping may increase the incidence of dual users of nicotine products. There is growing evidence that rather than substitute conventional tobacco for e-cigarettes, there are more dual users—those who vape and smoke cigarettes.

4. ENDS may be linked to future cases of lung cancer.5 Due to the contemporary nature of this epidemic, the long-term consequences of this health risk are unknown. However, due to historical data associated with nicotine use, it is highly suspect that a link between e-cigarettes and cancer will unfold.

Oncology nurses must keep up with the evolving scientific basis of the perils of vaping.

As trusted educators, we need to maintain informational vigilance about this health hazard. This topic may evolve in discussions with patients as the use of cannabis products during cancer treatment is deliberated. It may also present as patients and families voice concern about their children’s or grandchildren’s use of ENDS. I don’t feel this phenomenon will go away soon, which is all the more reason to focus on our evidence-based astuteness as we advocate for patients and families and perhaps our own loved one.

Marcham CL, Springston JP (2019). Electronic cigarettes in the indoor environment. 

Warning letter to JUUL Labs; accessed 10/10/2019; 

https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/juul-labs-inc-590950-09092019

Surgeon General’s advisory on e-cigarette use among youth. Washington D.C.: Department of Health and Human Services, Office of the Surgeon General, 2018 (

https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018-pdf

Henry TS, Kligerman SJ, Raptis CA, Mann H, Sechrist JW, Kanne JP (2020). Imaging findings of vaping-associated lung injury. 

Author (2019). Vaping-related lung illnesses: Time to act. 

Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME (2019). Trends in adolescent vaping, 2017-2019. 

Layden JE, Ghinai I, Pray I et.al. (2018). Pulmonary illness related to e-cigarette use in Illinois and Wisconsin — Preliminary report. 

Butt YM, Smith ML, Tazelaar HD et.al. (2019). Pathology of vaping-associated lung injury. 

Hswen Y, Brownstein JS (2019). Real-time digital surveillance of vaping-induced pulmonary disease. 

Tang M, Wu X, Lee H et.al. (2019). Electronic-cigarette smoke induces lung adenocarcinoma and bladder urothelial hyperplasia in mice. 

Yuan M, Cross SJ, Loughlin SE, Leslie FM (2015). Nicotine and the adolescent brain. 

Kandel ER, Kandel DB (2014). A molecular basis for nicotine as a gateway drug. 

The Disordered Mind: What Unusual Brains Tell Us About Ourselves. 

Brandon KO, Simmons VN, Meltzer LR et.al. (2019). Vaping characteristics and expectancies are associated with smoking cessation propensity among dual users of combustible and electronic cigarettes. 

Giovenco DP, Delnevo CD (2018). Prevalence of population smoking cessation by electronic cigarette use status in a national sample of recent smokers. 

Articles

Tobacco use among young people is an old problem that now challenges a new generation in a new form: vaping.

Vaping Presents an Old Danger to a New Generation

Nurses often ask me which sessions they should attend when going to an oncology nursing conference, but there is no standard reply. It takes some homework to ensure that they get the most out of their conference experience. They should tailor their plan as much as possible. For example, nurses should consider if the topic of a session is unfamiliar to them and something they want to learn more about. Is the focus an issue that is causing struggles at work? Is it a peripheral theme that does not directly affect current nursing practice but likely will in the future?

Over the decades, I have attended hundreds of conferences. Because of my extensive track record in continuing education, I have some thoughts about what nurses should consider before day 1 of an event.

First, scrutinize the schedule. Highlight the titles that seem appealing. Then, if available, look at the session descriptors and goals. Knowing this information might influence the decision to attend or not. Lastly, consider the speaker. Is this a recognized opinion leader on the topic? Have they written about the theme of the session? Ask colleagues who have attended similar offerings if they have heard that person present. If so, did the speaker connect with the audience, provide practical information—not just read the slides&mdash; and offer new information of relevance to the participants? All these components are critical musts to maximize learning.

Second, look for offerings that are different from the typical didactic session. There is only so much a person can absorb when someone else does all the talking and you do the listening. Is there evidence in the brochure that the presenters will use videos, role-playing, small group sessions, case studies with an audienceresponse format, or other types of novel teaching methods? Engagement is the key factor here.

Third, before attending the conference, be sure to check the listing about the availability of handouts and copies of slides. Get these in order before departing for the conference. I put these materials in a binder arranged by the day so that I am organized at the outset. It’s also important to bring several highlighters and take notes liberally. When listening to a lecture, I often find myself triggered to consider something new or am made aware of a related concept. For example, I was listening to a talk on neuro-oncologic emergencies, and much of the information being presented focused on seizure management and cognitive changes. I found myself thinking, “What about patients driving? Are there criteria to consider in offering advice about

Fourth, don’t assume that a major conference won’t give attendees an opportunity to share their views. Look for roundtable discussions and opinion panels for which the audience is asked to contribute. Many times, these interactive formats are the most informative. Also, the networking that transpires can be invaluable. Ask for new colleagues’ contact information. Look for opportunities to increase your peer network. At lunch, look for unfamiliar faces and sit at that table. At social events, try an introduction such as “I think I saw you in the town hall meeting. What did you think when they said…?” Following a particularly impressive or enjoyable session, approach the speaker to find out if he or she is open to being contacted later.

Attending a major conference provides the opportunity to look outside your own little box. Your world expands. You are on the receiving end of new information and become enlightened. You feel validated when you hear that you are doing a procedure in the ideal manner. More than once, I have heard colleagues say something along the lines of “Well, we’ve been doing that for a year now.” You may also be energized to prepare an abstract for a future conference.

Lastly, I know participants frequently get tired of hearing about the importance of filling out evaluations, but this step is critical. Conference planners look at the evaluations closely. Attendees’ opinions are heard, especially when they offer suggestions to improve an element of the education. Taking action to better the offering affects future attendance and, ultimately, revenue.

I challenge nurses to change their way of thinking about conference attendance. It requires more than a passive stance of showing up, sitting for long periods of time, and listening. To maximize conference participation, take an active role in analyzing, synthesizing, and configuring the educational experience based on your individual learning needs. Enlightenment is worth it.

Five tips on how oncology nurses can maximize the benefits of meeting attendance.

Plan Ahead to Get the Most Out of Conferences

Excess body weight (EBW) is an established cause of cancer in multiple solid tumors, including colorectal, esophagus, stomach, liver, gallbladder, pancreas, female breast, uterine, ovarian, renal, thyroid and multiple myeloma.

 In the United States, incidence rates of these malignancies have increased.

 State-specific incidence of EBW was recently delineated in an effort to augment national cancer control initiatives.

Using de-identified public data, the body mass index (BMI) of adults 30 years of age and older in all 50 states was used to determine the association between weight and various cancers. Overall, each year, about 37,670 cancer cases in men and 74,690 in women were attributable to EBW.

In general, women had EBW associations with cancer twice as high as men. The largest correlation with EBW and cancer was identified in southern and mid-western states as well as Alaska and the District of Columbia. State by state, EBW was noted to account for 1 in 17 incident cancers in all 50 states.

Overall, lifestyle behaviors such as excess weight and sedentary norms are estimated to contribute to 30%-40% of all cancer cases.

weight control, diet, and level of physical activity are not only modifiable determinants of initial cancer risk but also of cancer progression following diagnosis.

 In women’s malignancies, like female breast, endometrial, and ovarian cancer,  this association is particularly relevant.

Oncology nurses can be invaluable ambassadors in the promotion of cancer prevention. While many oncology nurses may not have pursued this yet they have great potential to prove influential in public awareness. Perceived as highly credible teachers, we have the capability to enlighten and influence the lay public about modifiable cancer risk. Additionally, in acknowledging that EBW is more common in lower socioeconomic groups, oncology nurses practicing in these settings are especially positioned to contribute to and enhance widespread community education. From a policy perspective, we can lobby to reduce access to, and marketing of, unhealthy foods (i.e., via taxation of sugar-laden drinks and foods).

While oncology nurses have historically focused on their roles within active cancer therapy settings, it is timely to consider expanding our influence to encompass cancer prevention.

Lauby-Secretan B, Scoccianti C, Loomis D, Grosse Y, Bianchi F, Straif K (2016). International Agency for Research on Cancer Handbook Working Group: Body fatness and cancer — Viewpoint of the IARC Working Group. 

Steele CB, Thomas CC, Henley SJ et.al. (2017). Vital signs: Trends in incidence of cancers associated with overweight and obesity — United States, 2005-2014.  

slami F, Sauer AG, Gapstur SM, Jemal A (2018). Proportion of cancer cases attributable to excess body weight by U.S. state, 2011-2015

4.World Cancer Research Fund (WCRF) (2007). 

Food, nutrition, physical activity, and the prevention of cancer: A global perspective.

 World Cancer Research Fund/American Institute for Cancer Research: London.

5.Rohan EA, Miller N, Bonner F et.al., (2018). Comprehensive cancer control: Promoting survivor health and wellness. 

6. Meyskens FL, Mukhtar H, Rock CL et.al. (2016). Cancer prevention: Obstacles, challenges, and the road ahead

, 108(2): djv309; DOI: 10.1093/jnci/dvj309.

7. Arthur R, Kirsch VA, Kreiger N, Rohan T (2018). A healthy lifestyle and its association with risk of breast, endometrial, and ovarian cancer among Canadian women. 

8.Arthur R, Wassertheil-Smoller S, Manson JE et.al. (2018). The combined association of modifiable risk factors with breast cancer risk in the Women’s Health Initiative. 


While oncology nurses have historically focused on their roles within active cancer therapy settings, it is timely to consider expanding our influence to encompass cancer prevention.
 

Excess Body Weight and Cancer: A National Perspective

In assuming the new role of editor in chief of 

®, I find myself thinking about the future. I challenge my fellow nurses to do the same.

Many years ago, I remember hearing a speaker tell the audience that just as you think back on what cancer care was like when you started your career and you consider all the changes that have occurred since then, you must assume that as you look forward, an equivocal amount of change will ensue. The take-home message is clear: Tomorrow’s cancer care and cancer nursing will not look like it does today. It is critical, then, that we take a proactive stance toward this evolution in care rather than a reactive one. Case in point: drug delivery of antineoplastics.

The significant trend toward the oral formulation of oncolytics has already started. Most likely, we are just realizing the tip of the iceberg. As of 2013, 30% of existing anticancer agents and another third of those in the development pipeline are orally formulated.

 With the administration of oral therapies comes the shift of drug delivery responsibility from the oncology nurse to the patient with cancer. We are in the midst of a real paradigm change within our specialty.

Patients are now expected to take their medications independently outside of the healthcare environment and selfmanage adherence and toxicity management. Less contact with the cancer care team correlates with decreased potential for face-to-face problem solving.

Overall adherence to oral oncolytics is estimated to be between 50% and 90%.

 How does this contribute to response rates and outcomes of clinical trials?

The reality is that we don’t really know how patients are managing their oral regimens. We have only cursory evidence of the reasons why patients do not take their medications as prescribed. Is it cost, poor memory, misunderstanding, literacy issues, or concerns about adverse events? Until we have assays that measure drug concentrations rather than relying on drug diaries and pill counts, there is no preferred way to measure adherence. Additionally, we must consider the phenomenon of overadherence. What about those who believe more is better? How does this contribute to toxicity burden and organ impairment? Although these “big picture” adherence issues are scrutinized and researched, we need to consider the following:

Don’t ask, “Are you having trouble taking your medications?” but rather, “What problems are you having?” Assume patients are not taking their medications 100% of the time. In one infusion center I visited, new patients were required to pick a “medication partner.” Usually this was an immediate family member or close friend whose designated role was to collaborate with the patient on their oral regimen adherence.

Nurses working with patients receiving oral oncolytics need to identify methods to keep in close contact with patients via email and video chat options. Nurse navigators are in a unique position to champion this effort. A recent review of interventions to improve oral chemotherapy safety and quality revealed that 2 of the interventions with statistically significant improvements were nurse coordinated; namely, implementing nurse phone calls within the first few days of treatment initiation and having standardized toxicity-management protocols that codified interventions for problems so nurses can provide consistent advice to patients.

In thinking about the future, we must also anticipate changes to the role of the ambulatory chemotherapy nurse. As infusion chair numbers fall, nurses may be asked, or expected, to assume the role of adherence nurse. The historic ambulatory medical oncology nurse role will most likely evolve from that of administrator to coach.

Novel trends in cancer therapeutics are happening here and now. We must embrace opportunities to consider new ways to nurse. These include fine-tuning skill sets for our roles as advocates, motivators, and problem-solvers within the mosaic of highly complex cancer care.

1. Geynisman DM, Wickersham KE. Adherence to targeted oral anticancer medications. Discov Med, 2013;5(83):231-241. discoverymedicine.com/Daniel- M-Geynisman/2013/04/25/adherence-to-targeted-oral-anticancer-medications. Accessed December 11, 2018.

2. Hershman DL. Sticking to it: Improving outcomes by increasing adherence. J Clin Oncol, 2016;34(21):2440-2443. doi: 10.1200/JCO.2016.67.7336.

3. IMS Institute for Healthcare Informatics. Global Oncology Trend Report: A Review of 2015 and Outlook to 2020. Parsippany, NJ: IMS Institute for Healthcare Informatics; 2016. morningconsult.com/wp-content/uploads/2016/06/IMSInstitute- Global-Oncology-Report-05.31.16.pdf. Published June 2016. Accessed Dec. 12, 2018.

4. Paolella GA, Boyd AD, Wirth SM, Cuellar S, Venepalli NK, Crawford SY. Adherence to oral anticancer medications: Evolving interprofessional roles and pharmacist workforce considerations. Pharmacy (Basel). 2018;6(1). doi: 10.3390/pharmacy6010023.

5. Cardoso E, Csajka C, Schneider MP, Widmer N. Effect of adherence on pharmacokinetic/ pharmacodynamic relationships of oral targeted anticancer drugs. Clin Pharmacokinet. 2018;57(1):1-6. doi: 10.1007/s40262-017-0571-z.

6. Zerillo JA, Goldenberg BA, Kotecha RR, Tewari AK, Jacobson JO, Krzyzanowska MK. Interventions to improve oral chemotherapy safety and quality: a systematic review. JAMA Oncol. 2018;4(1):105-117. doi: 10.1001/ jamaoncol.2017.0625.

“We are in the midst of a real paradigm change within our specialty.”

Oral Oncolytics Are Changing Nursing Practice

Numerous risk factors and etiologies for patients’ non-adherence to medication regimens have been identified in general populations and those with cancer.

, polypharmacy, advanced age, family influence, and toxicity avoidance. Rarely, however, has gender been cited as a risk factor for non-adherence to medication regimens among patients with cancer.

A recent study from Taiwan focused on the relationship between sex and analgesic 

 in nearly 400 patients in an oncology out-patient department, and showed some surprising results.

In the Taiwanese study, 3 domains were addressed:

Overall, women reported more hesitancy to use analgesics, lower adherence to the recommended plan of care, inadequate pain control, and ultimately experiencing more pain. The researchers concluded that women with cancer should be considered a high-risk group for achieving optimum pain control; however, reasons for this finding were not proposed. 

Results of this research prompt the need for further exploration of the relationship between gender and adherence within cancer care. Only 5 studies have previously addressed this phenomenon.

 A multifactorial approach is required as this entity is complex and influenced by personal, social, financial, psychological, and cultural variables.

Oncology nurses at the bedside are key to the exploration of this phenomenon due to their central and ongoing relationships with patients.  In the meantime, nurses can undertake their own field studies. Do you observe this phenomenon in your own practice?

Kini V, Ho PM.  Interventions to improve medication adherence: A review. 

Yilmaz F, Colak MY. Evaluation of inappropriate medication use and compliance in elderly people. 

Finitsis DJ, Vose BA, Mahalak JG, Salner AL. Interventions to promote adherence to endocrine therapy amongst breast cancer survivors: A meta- analysis. 

Krikorian S, Pories S, Tataronis G, et al. Adherence to oral chemotherapy: Challenges and opportunities. 

Chou PL, Fang SY, Sun JL, Rau KM, Lee BO. Gender differences in cancer patients’ adherence to analgesics and related outcomes of pain management. 

Turk DC, Okifuji A. Does sex make a difference in the prescription of treatments and the adaptation to chronic pain by cancer and non-cancer patients? 

Miaskowski C. Gender differences in pain, fatigue, and depression in patients with cancer. 

Edrington JM, Paul S, Dodd M, et al. No evidence of sex differences in the severity and treatment of cancer pain. 

Donovan KA, Taliaferro LA, Brock CW, Bazargan S. Sex differences in the adequacy of pain management of patients referred to a multidisciplinary pain clinic. 

Liang SY, Wang TJ, Wu SF, et al. Gender differences associated with pain characteristics and treatment in Taiwanese oncology outpatients. 

A Taiwanese study focused on the relationship between gender and analgesic adherence in cancer patients and shows some surprising results.

Does Gender Influence Adherence?

Cancer causes significant financial adversity within the American healthcare system.

Hence, the costs associated with cancer are often characterized using negative descriptors such as burden, toxicity, and harm. This includes hardship on patients and their families attempting to recover from this life-threatening illness.

 addressed total expenditures on anti-cancer drugs in the US between 2011 and 2016.

 Overall, expenditures rose from $26.8 billion in 2011 to $42.1 billion in 2016, with the greatest escalation in costs evident in 2015 (15.6% from the previous year). This was most likely correlated with the rising availability and use of targeted therapies during this timeframe.

These rising drug-related costs are trickling down and affecting the pocketbooks of patients and their families. High insurance deductibles, premiums, and uninsured populations are contributing to the growing number of Americans who are worried about or unable to afford the contemporary cost of cancer treatment.

In another study published in the same journal, researchers

found that out of nearly 2,000 adult patients with cancer who were identified through a health registry/survivor cohort, 26% agreed that the definition of financial toxicity is: “having to pay for more medical care than you can afford.”

Respondents in this group were characterized as individuals who fell into 1 or more of these categories: under 65 years of age, female, nonwhite, non-English speaking, unmarried, less educated, and having received a cancer diagnosis within the immediate timeframe of their questionnaire completion. Other significant attributes of this group were an increased likeliness to report noncompliance with medications, forgo mental health support, follow up with physician’s visits, and receive recommended medical tests. These individuals most commonly cited reasons for delayed or missed care as the absence of insurance coverage associated with the weighed decision of paying for cancer care versus affording household expenses.

While historically, oncology nurses focused on the physiological toxicity of therapies, we now have to address new barriers to optimal patient care. Existing resources to address financial toxicity may be scarce within some oncology practice settings. Oncology nurses need to acknowledge this and do more to identify resources to assist with this threat to the quality of our patients’ survival.

Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial hardships experienced by cancer survivors: A systematic review. 

Hong SJ, Li EC, Matusiak LM, Schumock GT. Spending on antineoplastic agents in the United States, 2011 to 2016

Tran G, Zafar SY. Financial toxicity and implications for cancer care in the era of molecular and immune therapies. 

Knight TG, Deal AM, Dusetzina SB, et al. Financial toxicity in adults with cancer: Adverse outcomes and non-compliance. 

Oncology nurses must acknowledge patients’ concerns about financial toxicity and help address them.