Nearly half of cancer patients do not discuss sexuality with their healthcare providers, but that doesn’t mean it isn’t a concern for them, according to Anne Katz, RN, PhD, a Clinical Nurse Specialist with CancerCare in Manitoba, Canada, addressing a large audience at the 2014 ONS Congress. Although patients may be reluctant to discuss the issue, Katz said there are “no excuses” for nurses not to educate them.

Katz polled the audience of her peers about their own level of comfort in discussing sexuality with their cancer patients. Not surprisingly, the responses from this motivated group of attendees were weighted well toward the comfortable side, with 19% describing themselves as “very comfortable” in discussing sexuality with patients and 65% as “somewhat comfortable”. Only 11% said “if my manager is watching”, and a mere 5% characterized discussion of sexuality as “someone else’s job.”

The number one barrier to healthcare practitioners discussing sexuality, said Katz, is lack of knowledge.  Other barriers include conservative attitudes, fear of embarrassing themselves, or fear of offending the patient.

One study Katz described indicated that clinicians were also concerned about how they would be viewed by their colleagues if they were known to routinely discuss sexuality with patients. Denial of responsibility and institutional issues were also listed as factors contributing to failure to broach the topic with patients, but Katz emphasized that nurses have a professional and ethical duty to educate patients and reminded them that ONS already has firm guidelines on their responsibilities in this area.

Katz asserted that while some providers may hide behind a “medicalized” approach, employing Latin terms and other means of avoiding direct discussion of sexuality, nurses are ideally positioned to assume leadership roles in discussing this critical issue in the lives of their patients.

“Nurses are the number one trusted health professional, and that trust should give us the confidence to raise this topic with our patients,” said Katz.

Prehabilitation, the interval between cancer diagnosis and start of treatment, is the ideal time to perform a physical and psychological assessment to enable discussion of upcoming changes. Katz said that changes to sexuality must be included in that discussion.

She described several models of sexual assessment that therapists use to assist in the diagnosis and treatment of sexual dysfunction. These models are also appropriate for use in disturbances to sexuality which may occur as a result of cancer and cancer treatment, she said, and they include PLISSIT (Permission, Limited Information, Specific Suggestion, Intensive Therapy), created in the mid-1970s, and its whimsically-named successor, EX-PLISSIT (

A more recent model, said Katz, known as BETTER, created in 2003, is focused on provoking dialogue and building a trusting relationship between the healthcare practitioner and the patient. She added that another model which has potential for use in addressing sexual issues related to cancer treatment is one designed for smoking cessation therapy known as Bober’s 5-A’s (Advise, Ask, Assess, Assist, Arrange).

Regardless of what assessment model might be used, Katz encouraged her audience to rehearse their opening line, perhaps in front of the mirror, which would allow them to get the conversation started.

For example: Katz offered the following sample lead-in to a discussion of sexuality with a patient: “Women who have a hysterectomy often have concerns about what changes they may experience in their relationships.” After delivering the lead-in, Katz urged the nurses to wait as long as necessary for the patient to break any ensuing silence.

Katz also elaborated upon some of the more common sexual-related side effects of cancer treatment. Men who have undergone radical prostatectomy could suffer erectile dysfunction, while women on taxanes or aromatase inhibitors might have issues related to low estrogen making intercourse painful. Anti-androgen therapy might result in psychologically devastating genital shrinkage for men, whereas women with mastectomies could experience equally debilitating psychological impacts on their sexuality.

Although noting differences in arousal patterns between men and women, Katz also stressed the importance of outwardly nonsexual aspects of couples’ relationships which might be impacted by changes brought on by cancer treatment, aspects which can be mediated by both verbal and nonverbal modes of communication.

Simple touching between partners, a nonsexual prelude to greater intimacy, is often lost due to psychological factors resulting from response to disease or therapy, but communication can help restore these prerequisites to sexual activity.

“Communication lies at the root of all our relationships. We work in an environment where communication is of upmost importance.”

In conclusion, Katz restated her belief that nurses are best suited for communicating with patients on sexuality. “We understand the treatments, we understand what cancer is, and most important of all, we understand our patients. We do it better, plain and simple.”

View more from the 2014 ONS Annual Congress

Articles

Nearly half of cancer patients do not discuss sexuality with their healthcare providers, but that doesn't mean it isn't a concern for them.

Nurses at the Frontline of Important Discussions of Treatment-Related Sexual Side Effects

Advances in precision medicine for the treatment of melanoma  include novel small-molecule inhibitors targeting signal transduction pathways in 

 mutations and cutting-edge drugs in the area of immune-modulation, whereby the patient’s own immune system is mobilized to attack the tumor. Despite improved efficacy with these new therapies, both as monotherapy or in combinations, they provide new challenges to nurses in managing side effects and adjusting treatment; these advances and subsequent challenges were detailed May 2, 2014, during a presentation at the ONS 39

Brianna Hoffner, MSN, AOCNP, nurse practitioner and supervisor of Clinical Research Operations at The Angeles Clinic and Research Institute in Santa Monica, California, and Matthew Burke, MBA, RN, MSN, APRN-BC from Yale-New Haven Hospital in Connecticut, both presented on the topic.

Melanoma is the fifth most common cancer in the United States, with over 75,000 new cases in 2013 and nearly 1 million melanoma patients currently living with the disease. Although melanoma accounts for only a small percentage of skin cancers overall, it is responsible for the majority of skin cancer deaths, and incidence of melanoma is increasing faster than that of any other cancer. Fortunately, melanoma is also one of the most active research areas in oncology in terms of emerging treatment modalities.

Ipilimumab (antiâ€CLTAâ€4) is a first-in-class humanized monoclonal antibody approved for treatment of melanoma. Ipilimumab may activate a patient’s immune system for a vigorous and sustained antitumor response by blocking the activity of the CTLAâ€4 receptor on T lymphocytes. Unlike targeted therapies, where tumor cells can evolve to circumvent various types of signaling inhibition, immunotherapy, such as ipilimumab, provides a durable response that may last for years.

However, this same mechanism can lead to potentially severe or life-threatening adverse events. “The introduction of ipilimumab onto the market has led to a whole new area of immune-mediated adverse events. Our role as nurses and nurse practitioners in understanding how to manage patients through this therapy has become vital,” said Burke.

Side effects from immunotherapies such as ipilimumab are characterized as immuneâ€mediated adverse events (IMAEs). The most common IMAEs from ipilimumab include enterocolitis, hepatitis, dermatitis, and endocrinopathies. Toxicity may emerge after several weeks of therapy, and 10% to 15% of patients experience a severe or life-threatening (grade 3 or 4) toxicity. Treatment interruption and early administration of corticosteroids are essential for effective management of IMAEs.

Important variances in tumor response may occur with immune modulators, which can be disturbing to caregivers; namely, initial post-treatment growth of tumors prior to shrinkage or the temporary development of additional distant tumors. Response Evaluation Criteria in Solid Tumors (RECIST) criteria may not accurately capture tumor responses seen on radiographic imaging after administration of immunotherapy. A useful alternative to RECIST that has been developed is immune-related response criteria (irRC), which addresses response patterns characteristic of those observed post-administration of immunotherapies.

The next generation of immune-modulating antibodies that are currently in clinical trials target either the programmed death-1 receptor (PDâ€1) or one of its ligands, PD-L1.  PD-1 is also a Tâ€cell receptor and has a structure similar to that of CLTAâ€4. While PD-1 has a distinct biologic function and ligand specificity, inhibiting binding of PD-L1 to the PD-1 receptor also has the effect of activating an immune response against the tumor. Durable responses and promising improvements in overall response rates and overall survival have been seen in trials of these agents. While antiâ€PDâ€1/L1 toxicity has been somewhat lower than that observed with anti-CTLA-4, grade 3 or 4 IMAEs have been seen, along with a variety of autoimmune side effects. The most commonly observed events included pneumonitis, vitiligo, colitis, and hepatitis.

Combining antiâ€CTLAâ€4 and antiâ€PDâ€1 therapy appears to provide a higher level of antiâ€melanoma activity than does either agent alone. Once anti-PD-1 antibodies are approved, concurrent antiâ€CLTAâ€4 and antiâ€PDâ€1 treatment will become more common, resulting in a slightly different suite of issues for nurses to address.  Most common severe AEs involved in combining immune-modulatory agents include hepatotoxicity, gastrointestinal issues, and renal toxicity.

 mutations are found in approximately 50% of melanomas, with mutations to 

are found in another 25%. There have been dramatic advances in the development of signaling inhibitors to counteract mutations in melanomas. Numerous therapies targeting the Rasâ€Rafâ€MEKâ€ERK signaling pathway, such as BRAF inhibitors for 

-mutated melanomas, are now available. BRAF inhibitor therapy can display response rates as high as 50%, and these may occur rapidly. The FDA has approved two BRAF inhibitors, vemurafenib and dabrafenib. While effective, dermatologic side effects to these treatments may include severe photosensitivity, and development of rashes, squamous cell carcinomas, or additional melanomas.

Inhibition of MEK provides another angle for treating not only 

-mutations. Currently trametinib is the only FDA-approved MEK inhibitor. Single-agent trametinib therapy is associated with a nearly 50% response rate. Side effects can be ocular, dermatologic, hepatic, or cardiac in nature. BRAF inhibitors can now be combined with MEK inhibitors, since combination therapy of dabrafenib plus trametinib was FDA approved earlier this year based on response rates of over 75% seen in clinical trials.

Addressing the issue of side effects with dual therapy, Hoffner said, “The side effects with the combined agents is similar to the monotherapy. However, the really interesting thing about BRAF plus MEK is that oftentimes the combination is tolerated better than a single agent.”

The complexity of emerging melanoma therapies continues to increase with the prospect of combining targeted inhibitors with one or more immuno-modulatory agent. An additional layer of complexity has arisen from agent sequencing strategies, and a multitude of permutations are currently being tested in clinical trials.

Advances in precision medicine for the treatment of melanoma  include novel small-molecule inhibitors targeting signal transduction pathways in BRAF and NRAS mutations and cutting-edge drugs in the area of immune-modulation, whereby the patient's own immune system is mobilized to attack the tumor. 

Advancements in Melanoma Present New Challenges for Nurses

With an increasing number of cancer therapies being delivered orally, the importance of adherence continues to grow, and efforts to adapt adherence programs from other conditions like HIV could lead to better outcomes.

When treating HIV, adherence to prescribed medication schedules is strongly related to the degree and durability of viral suppression and is associated with decreased rates of progression, hospitalization, and mortality. HIV therapies are similar to oral cancer therapies in many respects. The regimens are complex, with multiple side effects, a high degree of toxicity, and a high pill burden.

Adherence programs that emphasized individual interventions, as well interventions of longer duration and those targeting practical medication management skills, met with greater success than initiatives that focused on behavioral or motivational approaches, according to Pamela Ginex, EdD, RN, OCN, a nurse researcher at Memorial Sloan Kettering Cancer Center in New York, in a podium session May 1 at the 39th Annual Oncology Nursing Society Congress in Anaheim, California.

Oral oncolytics offer the advantage of greater patient convenience, no need for IV access, the ability to achieve sustained drug levels, and minimal disruption to the patient’s daily life. However, disadvantages include increasing the distance from provider to patient, with fewer safeguards for administration, and patients bearing more responsibility for their own care.

In their key position as caregivers, nurses are seen as crucial to maintaining adherence. Nurses should be involved in the early process of establishing adherence, as nurses are more likely to consider factors involving the family and living situation than other healthcare professionals—factors that may have a significant impact on whether a high degree of adherence occurs, said the researchers.

“Nurses, in collaboration with other healthcare professionals, play a pivotal role in developing and implementing those studies,” said co-presenter Laura Fennimore, RN, DNP, director of Clinical Programs at the University of Pittsburgh Medical Center (UPMC) Health Plan. “Nurses continue to be the best advocates for our patients on oral treatment.”

Fennimore classified the various factors influencing adherence into categories of patient condition, type of therapy administered, and factors related to clinicians. Patient condition—related factors include cognitive impairment, comorbidities (particularly depression), anxiety, beliefs about treatment and outcome, health literacy, and substance abuse. Family stability and social support are crucial to adherence success as well.

Therapyâ€related factors include the types of side effects that might occur, the length and complexity of treatment, pattern of dosing, and interactions with other prescribed medications. Simple dosing presents the fewest challenges, but 10% to 40% of patients on even a simple regimen still had imperfect dosing. Adherence is also seen as inversely proportional to frequency, with average adherence rates of just 50% for four times—daily dosing. Clinicianâ€related factors were said to include quality of aftercare management, communication skills, belief in treatment, and quality of provider–patient relationship.

Based on studies in oral chemotherapy for cancer and in the field of HIV treatment, both educational and technologically-based interventions show considerable promise to increase adherence, said the researchers. However, more research on what constitutes effective strategies for boosting adherence is needed.

“Oral therapy for cancer treatment is here to stay and only going to increase as additional agents are developed,” the presenters concluded, and “nurses should have a significant presence in planning for patients care,  research, and guidelines related to oral cancer treatment.”

Among the resources available to help nurses optimize patient adherence to oral medications is the ONS Oral Adherence Toolkit, available at 

https://www.ons.org/sites/default/files/oral%20adherence%20toolkit.pdf

Nurses Can Adapt Programs From Other Conditions to Improve Oral Therapy Adherence

Effectively communicating with patients about what to expect before and after cancer treatment is an essential element of patient care. Several new patient education strategies which nurses may want to try in their own practices were spotlighted in studies presented by four nurse researchers at the 2014 ONS Congress.  

Amy Singer, MSN, RN, from the Ohio State University James Cancer Hospital and Solove Research Institute in Columbus, discussed a booklet that nurses there developed in collaboration with their patient education department, describing what patients scheduled for breast biopsy should expect. The motivation to create this educational tool came from patient feedback on how to improve existing one-on-one patient teaching sessions conducted by the nursing staff. Before launching the project, staff anticipated that use of the booklet would promote active engagement on the part of biopsy patients and bolster nurse—patient relationships.

After using the booklet for 3 months, a survey was conducted to evaluate its impact. Of 27 patients who responded, all indicated that it was an effective teaching tool for learning what to expect before, during, and after breast biopsy. Over three-fourths of respondents agreed strongly that the material in the booklet was easy to read and to understand, and over two-thirds approved of the way the material was organized. Patients made useful recommendations for the addition of section tabs in future versions of the booklet to facilitate searching for specific information.

Promoting Patient Compliance After Discharge

	The patient education efforts of Molly Henneberry, RN, OCN, and colleagues at the Billings Clinic in Montana, focused on post-discharge follow-up of acute care patients to facilitate better patient compliance with discharge instructions and provide more effective identification of patient needs, improve patient care, and decrease readmission rates.

	A review of the medical literature had revealed that telephoning patients post-discharge could both decrease anxiety and reinforce discharge instructions. Given that little was known regarding outcomes in the growing practice of post-discharge calls to patients with cancer, oncology nurses at the Billings Clinic developed guidelines for calling patients post-discharge. All phone conversations were documented in the electronic record.

Since initiation of the program, over 1000 patients with cancer have been called post-discharge and assessed regarding pain, nutrition, elimination, and medication adherence, as well as to confirm follow-up appointments and patient comprehension of discharge instructions. Henneberry stated that fewer readmissions and adverse events had occurred thanks to early recognition of uncontrolled symptoms, disease progression, or patients’ misunderstandings of discharge instructions.

Denise Fleming, RN, BSN, OCN, from the University of California Davis Health System, Comprehensive Cancer Center in Sacramento, presented on pretreatment education efforts there for patients soon to undergo chemotherapy treatment. Again, the communication medium for education was the telephone.

Nurses at the Cancer Center designed and implemented a nursing prechemotherapy education phone call conducted the day before treatment to better prepare patients by setting expectations appropriately and helping to relieve anticipation anxiety. Many details not routinely addressed in the previous physician visit occurring a week or more previously were covered in the call.

A survey was developed to assess patient responses to the pretreatment call and to provide feedback for amending the call template. All 19 of the patients responding to the survey over the initial month of the program reported that the call had increased their satisfaction with the subsequent therapy and reduced their anxiety. When asked about any planned follow-up surveys, Fleming said,

“We are going to wait for a year out. With a 100% satisfaction rate, I don’t think we were going to find out anything different than what we were learning already from that one month.”

Participating nurses, who had been using valuable chemotherapy teaching time resolving preventable problems and conflicts on the day of treatment, felt that benefits of the proactive phone call included the identification of treatment obstacles or scheduling conflicts.

“We have a very set schedule that we need to operate on, kind of like a plane,” said Fleming. “We have a limited amount of time to do really precious chemotherapy teaching and we were using a lot of that time to explain things to patients that could have been done preemptively.” Fleming added that, “It’s good to get information, but the really beautiful thing was that the patients were walking in with a preexisting relationship with a registered nurse.”

Michelle Wasko, MS, BSN, RN, NE-BC, also from the Ohio State University James Cancer Hospital and Solove Research Institute, highlighted a post-discharge call and follow-up visit protocol established for blood and marrow transplant patients there

The purpose of the protocol was to address patient concerns and to decrease hospital readmission rates by calling patients within 24 to 48 hours of discharge to identify and address any issues before they became problems. Literature had suggested also that return visits can be instrumental in decreasing readmission rates.

An interdisciplinary team of nurses, physicians, nurse practitioners, and billing personnel analyzed each phone call and accompanying readmission information. Data were used to aid in determining how the facility might best incorporate new transitional care codes from the Center for Medicare and Medicaid Services (CMMS) for the fee schedules that allow for follow-up calls and clinic visits.

Over 2 months, the researchers found that readmission rates decreased an average of 6%, and patients reported satisfaction above national benchmarks.

Wasko and colleagues noted that the protocol is now being initiated with other patient populations, with the goal of implementing it throughout the entire cancer hospital.

“As outcome measures continue to drive future reimbursements, developing and implementing approaches to continuity of care for our transitional patients is paramount,” the research team noted, adding that the current protocol offers an innovative approach to impact overall readmissions and improve delivery of patient care.

Effectively communicating with patients about what to expect before and after cancer treatment is an essential element of patient care. 

Dennis Bittner, PhD

Articles

Nurses at the Frontline of Important Discussions of Treatment-Related Sexual Side Effects

Advancements in Melanoma Present New Challenges for Nurses

Nurses Can Adapt Programs From Other Conditions to Improve Oral Therapy Adherence

Communication Tools Help Patients Know What to Expect Before and After Cancer Treatment