Older age is a significant risk factor for many types of cancer. It is estimated that by 2030, 70% of patients with new cancer diagnoses will be 65 and older.

 It is imperative that nurses caring for geriatric patients understand the unique challenges their patients face to ensure that the care provided meets those needs.

®, Leana Cabrera Chien, MSN, RN, GNP-BC, and Jeanine Moreno, MS, APRN, AGNP-C, shared their insights on geriatric oncology nursing. Chien and Moreno, along with Carolina Uranga, MSN, RN, GNP, and Peggy Burhenn, MS, CNS, RN-BC, AOCNS, compose the Aging Wellness APN team at City of Hope Aging Wellness Clinic in Duarte, California, recently recognized by the Institute for Healthcare Improvement as an Age-Friendly Health System. 

As a board-certified geriatric nurse prac-titioner (NP), Chien has worked with older adults with cancer and participated in studies about such patients in various settings with the goal of improving their model of care. Whereas oncologists focus on treatment, the role of the NP goes further, focusing on the whole patient.

“The biggest difference in older patients is they come with a whole history obtained over a longer period of time,” Chien said. “Look at the whole person, their comorbidities, nutritional deficits, functional and/or cognitive decline, falls, depression, and concerns such as fatigue, which may be associated with other issues.” 

Conducting a comprehensive geriatric assessment will help clinicians evaluate and address age-related concerns and improve the quality of care they provide, individualized to meet the patient’s unique need. The American Society for Clinical Oncology (ASCO) Guidelines for Geriatric Oncology provide recommendations on the use of validated, standardized clinical assessment tools

Moreno, who is also a gerontological NP, heartily agrees. Before going to City of Hope, she had no experience working with patients with cancer, but merging her expertise in geriatrics with oncology has made her an invaluable asset.

“That first meeting to discuss a cancer diag-nosis is always overwhelming. It turns your world upside down, no matter your age or health,” Moreno said, adding, “Older adults, however, tend to face obstacles not typically experienced by younger patients.”

Comorbidities can also be affected by treatment, and vice versa. Patients with arthritis, for example, may experience flare-ups in pain from chemotherapeutic drugs. Education is key in helping patients understand that their existing conditions may change or be exacerbated in response to treatments. These conversations are ongoing and meant to help prevent additional problems from occurring. 

Moreno encourages nurses to look at everything going on with a patient and how it relates to their status and safety. “If a patient’s knees hurt too much to stand and cook, they will not eat as much. If their blood pressure is too low, they may pass out and hit their head.” Thorough assessment will identify these issues before a problem develops or an incident occurs.

Polypharmacy is another obstacle common with older adults. Chien shared a story about a patient with cardiac issues who experienced dizziness and frequent falls: “A medication review revealed the patient was taking amiodarone and an antidepressant, which was curious because this patient was always happy, cheerful, and upbeat. When asked about the antidepressant, she said it had been prescribed to her years ago after her husband passed away and no one had told her to stop taking it. Once the medication was discontinued, the dizziness improved and the falls stopped.”

It is not enough to know which medications a patient is taking and why; nurses also need to know how medications may interact and what effects those interactions may have. What may seem minor can make a big difference. 

Medication review includes both prescription and OTC drugs, looking at appropriateness, dosages, frequencies, effectiveness, and adverse events (AEs). Medications may need adjustments during treatment because of drug-drug interactions or patient status. Communication between members of the multidisciplinary team (primary care physician, pharmacist, oncologist, cardiologist, nursing, therapy, nutrition) when updating medication regimens or changes in condition helps ensure consistency and safety.

Cancer treatments are not easy, even for the young patient. Since Moreno began working in oncology, she has been shocked by how much a person can physically endure. Sometimes the decision is based on the wishes of their family. “Even when the prognosis is not great, some patients consent because it’s what their loved one wants,” she stated. Other patients may choose a different course, or one that the health care team may not think is best. Nurses need to honor whatever choice the patient makes, provided education about all the options available including risk and benefit has been given to the patient to make an informed choice. Sometimes the choice may be to forgo treatment. Patients may be unaware that declining treatment is also an option. 

Discussions on toxicity are important with patients considering chemotherapy. A validated chemo-toxicity calculator (along with a geriatric assessment tool) is available from the Cancer and Aging Research Group at www. mycarg.org. The toxicity calculator captures socio-demographics, tumor/treatment variables, lab results, and geriatric assessment items to predict the risk of severe AEs of chemotherapy in older adults that can guide decision-making. 

When looking at patients, consider their functional age, not merely chronological age. Two 90-year-old patients can differ greatly in their functional ability. “This is a huge teaching point for nursing staff,” says Moreno. “Some 90-year-olds are highly functioning, whereas some 65-year-olds are not.” Part of treatment includes preventing functional loss. Balancing rest with activity can be challenging, especially for patients over 85. They may be more afraid of moving or falling, which can be addressed through physical and/or occupational therapy. A key teaching point for both patients and family members is the importance of mobility to prevent loss of muscle mass. 

A recent pilot study conducted at Duke University testing the effectiveness and feasibility of academic-practice partnership for caregiver training and support demonstrated favorable outcomes for caregivers and older patients.

 The program included training on medical tasks in the home as well as follow-up phone calls to caregivers. Programs like this may be helpful prototypes for oncology nurses to consider for adaptation to the special needs of older patients and their families.

Older adults may have struggles with communication because of hearing deficits or cognitive decline, but what about technology? Are older adults less tech savvy than younger adults? Perhaps, but Moreno and Chien have found that most older adults can and do use computers. Research suggests the challenge is related more to resource limitations than ability or reluctance.

Resource limitations may apply to patients of any age, not just older adults. Since the COVID-19 pandemic, however, families have had to adjust to social restrictions, and have learned to use video platforms such as Zoom to visit and communicate with their loved ones. What may be a bigger hindrance to digital communication than technical savvy is poor internet service, especially in areas that are more rural. 

Face-to-face communication is always best, but telehealth has become a valuable tool for health care providers, patients, and their family members. Televideo allows providers to conduct geriatric assessments remotely, to see patients’ home environments, check their medicine cabinet, talk with multiple family members, and can ease the challenges of transportation for the older adult, especially when multiple appointments are needed. Physical and occupational therapy sessions may also be conducted via telehealth to increase strength and mobility.

For patients less adept with using technology, nurses should take the time to walk a patient through the app/resource/program they will be using. Some patients may not have a computer or a smartphone, and accommodations could be made with family members to bring a laptop to the patient’s home and assisting with its use. 

Multiple phone calls between provider and patient are commonplace in oncology. For older adults, they may need encouragement from family to make a call with a question or concern. More than 1 call may be necessary to change a routine or reiterate important information. Nurses find family input helpful, as they add to the conversation and provide information from a different perspective. 

Symptom monitoring technologies may also be helpful for older patients with cancer. A recently published study demonstrated that older adults had the same level of adherence as younger adults, and received similar benefits, using a telephone-based intervention, which did not require smartphones, computers, or Wi-Fi.

 The keys to effective, responsive communication are ensuring that methods used fit the patients’ needs and that messages are communicated clearly and received and understood as intended.

Oncology nurses will be best prepared to provide high-quality, individualized care to their older adult patients by becoming familiar with geriatric guidelines and assessment and learning more about age-related concerns of geriatric patients. Information and education is available from Nurses Improving Care for Healthsystem Elders at www.nicheprogram.org, the National Comprehensive Cancer Network at www.nccn. org and for providers at American Geriatrics Society at www.americangeriatrics.org.

1. Presley CJ, Krok-Schoen JL, Wall SA, et al. Implementing a multidisciplinary approach for older adults with cancer: geriatric oncology in practice. 

. 2020;20(1):231. doi:10.1186/s12877-020-01625-5

2. Mohile SG, Dale W, Somerfield MR, et al. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. 

2018;36(22):2326-2347. doi:10.1200/JCO.2018.78.8687

3. Hendrix CC, Matters D, Griffin T, et al. Academic-practice partnership for caregiver training and support: the Duke Elder Family/Caregiver Training (DEFT) Center. 

. 2020;81(4):221-227. doi:10.18043/ncm.81.4.221

4. Coombs LA, Ellington L, Fagerlin A, Mooney K. Age is not a barrier: older adults with cancer derive similar benefit in a randomized controlled trial of a remote symptom monitoring intervention compared with younger adults. 

. 2020;27(1):1073274820968878. doi:10.1177/1073274820968878

Articles

Oncology nurses must consider many factors when treating geriatric patients,  from drug-drug interactions to treatment education and functional age. 

Caring for the Geriatric Patient: What Oncology Nurses Need to Know

Annette Galassi, MA, BSN, OCN - photographed by Claudio Papapietro

In November 2011, Annette Galassi, MA, BSN, OCN, traveled to Ethiopia with the organization Health Volunteers Overseas to help start a new project. She had long wanted to volunteer and had a growing interest in oncology nursing in low-resource settings. When she ran across an advertisement in an oncology publication looking for nurses and doctors to volunteer, Galassi was in the right place in life and ready to commit. She followed the pull and applied.

Communicable diseases were coming under control in many places. People were living longer, but more were developing cancer.

 Access to cancer care was a growing problem, and Galassi wanted to help.

“Ethiopia had a population of 90 million people. They had 1 public hospital with 2 cobalt radiation machines for the entire country,” Galassi said in an interview with 

. “Patients presented with latestage, often incurable disease. Nurses had little or no personal protective equipment, and they would mix chemotherapy right at the bedside. Resources, supplies, and medication were extremely limited, as was knowledge about cancer and cancer care.”

Galassi made several trips to Ethiopia to help educate and train the nurses, and she and a colleague work with the school of nursing to draft a certificate program in oncology nursing. She sees a silver lining in partnerships like the one between the Addis Ababa University School of Nursing and Midwifery in Ethiopia and the University of Oslo in Norway to offer an oncology master’s program.

The issues facing low- and middle-income countries (LMICs) are complicated and multifactorial. Problems such as political and financial barriers to cultural views on cancer, as well as the undervalued role of nurses, can seem insurmountable.

But nurses such as Galassi, along with volunteer healthcare organizations that provide collaborative, sustainable programs and tailored approaches to problem solving, are leading to desperately needed improvements in cancer care. One top priority for oncology nurse volunteers is providing education and training for nurses, who provide most of the cancer care. Nursing education typically does not include training on cancer.

 Standards and protocols are often inconsistent or nonexistent.

Most patients in LMICs purchase their own chemotherapy medications and bring them to the hospital. By insisting that the nurse stay at the bedside to mix the drugs, they know they are getting what they paid for. Patients also pay for supplies out of pocket, and expect them to be resused.

Showing senior nurses how to perform skills and assessments and teaching them to instruct less experienced staff helps all involved grow and build confidence.

Some nurses may see patient education as the doctor’s responsibility and not realize that patients may need to hear information several times before they remember and understand or that, patients may feel more comfortable asking questions of a nurse than a doctor.

In many countries, nursing is not considered a prestigious profession. Galassi, who is involved in volunteer work with a pediatric oncology unit in Delhi, described the situation in India: “Nurses are often looked down upon and not treated as equal. This can get in the way of moving their practice forward.” She said her team worked hard to get nurses to competently assess and present patients’ problems to physicians, rather than passively taking orders, doing whatever the physician said, and never questioning anything.

“Physicians needed to understand that although they could teach about the disease process and action of drugs, they didn’t have the nursing expertise to teach nursing at the bedside, nursing assessments, [or] nursing interventions or how to conduct a root cause analysis for spikes in PICC [peripherally inserted central catheter] line infections, figure out potential reasons, and figure out what could be done to change things,” Galassi said.

Galassi, who continues volunteering in places like Bhutan and India, encourages nurses who are interested in global volunteer work to do their research when selecting an organization with which to partner.

Virginia LeBaron, PhD, APRN, ANCP-BC, FAANP, wholeheartedly agrees. LeBaron and Galassi coauthored a resource article for nurses interested in volunteering.

In 2004, LeBaron was working as an oncology nurse and palliative care nurse practitioner. She had always been interested in global health work, but struggled to find the right organizational fit. She eventually connected with a global oncology group working in partnership with countries to build palliative care capacity. It was a perfect match, and LeBaron made her own eye-opening first trip as a global oncology nurse volunteer in Nepal.

The volunteer organization’s work was based on sustainable partnerships, and they collaborated with healthcare providers to tailor their approach. LeBaron became involved in education about capacity building related to palliative care.

There were (and are) huge disparities in access to basic pain medicine.5 She worked in hospitals and saw that patients with late-stage cancer were unable to get prescriptions for morphine.

“There are multifactorial issues regarding pain medication,” LeBaron told 

. “There is a physical lack of supply of opioids. This lack is perpetuated and exacerbated by regulations that make if difficult for providers to prescribe medication or for pharmacies and formularies to stock medication.”

These factors contribute to what appears to be low demand, creating a cycle of inability to create enough supply, she said: “It circles back to regulations. Low demand is not lack of need. Need is great; supply and access are low.” Even when opioids are accessible, they may not be in the correct form. Intravenous (IV) morphine is not helpful for patients who need oral medication for home use.

Pain management and access to pain medication are issues not only in Nepal but also in many other low-income countries. For LeBaron, knowing that patients’ pain was not adequately managed set her on a path to explore how to improve that situation. She started working with other organizations related to pain management and policies around opioids. Around the same time, as she was completing her dissertation on access to opioids and pain management, issues began emerging about the opioid epidemic in the United States. Her research was caught in the crosshairs of patients suffering in agony without pain medication and the significant concerns about misuse and diversion of opioids.

“It is an interesting place to be,” she recalled. “People are asking, ‘How do we achieve balance between not putting patients and communities at risk but, at the same time, not contributing to the undertreatment of pain or stigmatizing opioid therapy for people who legitimately needed it?’” Now, in the United States, data are emerging about patients’ difficulty in accessing necessary pain management and the unintended effects of good-intentioned regulations. “Global health work is colliding with what’s happening domestically,” LeBaron said.

Lori Buswell, NP, MS, is the executive director at the Dana-Farber Cancer Institute’s Center for Global Cancer Medicine, which was established in 2012 and, alongside the nonprofit group Partners in Health (PIH), supports the advancement of cancer care in LMICs. She shared with Oncology Nursing News® about the work she has been involved with in Rwanda.

“In 2012, the center, PIH, and the Rwandan Ministry of Health kicked off a national weeklong training course for doctors and nurses throughout the country to raise awareness of what cancer is, what it looks like, and how it is treated. In-depth training was provided for hospitals that treat patients with cancer. Most of the chemotherapy was given at a hospital in Butaro because the drugs were free—PIH paid for them&mdash;or [at] the private hospital for patients who had money, could purchase the drugs, and be treated. There were only 2 places where people could get chemo and only 1 oncologist in the entire country. Now there are 4 [or] 5, although they are all in the capital city. The first radiation center didn’t open until 2019. Before then, patients were sent to Uganda and Kenya for radiation, also paid for by PIH.”

Volunteers from several cancer centers work in Butaro for a couple of weeks to teach nurses and physicians, including general practitioners, about oncology and how to take care of patients, Buswell said. They provide protocols for treating patients with cancer—how to work up, stage, and treat them. “Cancer is an interdisciplinary team event. We try to build expertise in all disciplines,” she said.

Buswell travels to Rwanda twice a year for 4 to 8 weeks. The volunteers help write policies and procedures to solidify what nursing practice should look like and encourage efficiency.

“One thing we did was to write down all the elements needed to administer chemo,” Buswell said. “Now they have a standard template for the patient to bring to the pharmacy and get everything needed.”

Although the need is great, opportunities are limited for volunteers, and it is important for nurses to realize that meaningful work requires an investment in time. “Volunteers who drop in for a week or 2 have helped a patient but haven’t helped the country build a workforce,” Buswell noted. Sending tubing, IV pumps, or 100 doses of medication also is not necessarily helpful. The real needs: sustainable partnerships and donations of time and money.

Buswell believes that it will take a couple of generations or more to get essential workforces in place. “There is great satisfaction, however, in paying it forward,” she said. “Global oncology volunteer work is incredibly satisfying on a personal and a professional level.”

Varmus H, Kumar HS. Addressing the growing international challenge of cancer: a multinational perspective. 

. 2013;5(175):175cm2. doi: 10.1126/scitranslmed.3005899.

Galassi A, Morgan C, Muha C. Making the invisible visible: oncology nursing efforts of NCI-designated cancer centers in LMICs. 

. 2018;17:34-37. doi: 10.1016/j.jcpo.2017.03.013.

Challinor JM, Galassi AL, Al-Ruzzieh MA, et al. Nursing’s potential to address the growing cancer burden in low- and middle-income countries. 

. 2016;2(3):154-163. doi: 10.1200/JGO.2015.001974.

Galassi A, Pradhan R, Palat G, LeBaron VT. Global oncology volunteering: making an effective contribution. 

. 2017;44(5):530-533. doi: 10.1188/17.ONF.530-533.

LeBaron VT, Palat G, Sinha S, et al. Recommendations to support nurses and improve the delivery of oncology and palliative care in India. 

. 2017;23(2):188-198. doi: 10.4103/IJPC.IJPC_153_16.

Volunteer nurses give their time and share their knowledge, empowering healthcare practitioners worldwide.

Global Oncology Nursing Improves Cancer Care Worldwide

Parents often become distressed or overwhelmed when their child receives a cancer diagnosis, especially if the prognosis is poor. Nurses must be sensitive to parents’ emotional needs when providing important information about the disease and safely caring for the child at home, and a number of strategies can help guide their interactions with parents.

In 2019, more than 11,000 children will be given a cancer diagnosis, and almost 1200 children are expected to die from the disease.

 Behind accidents, cancer is the second-leading cause of death for children aged 1 to 14 years, according to the American Cancer Society. But thanks to advances in cancer research and treatment, the survival rate for children has increased over the past 4 decades from 58% to more than 80%. The Children’s Oncology Group (COG) has played a pivotal role in improving outcomes for pediatric cancer through clinical trials, research, and education.

Wendy Landier, PhD, RN, CRNP, FAAN, an associate professor in the Division of Pediatric Hematology-Oncology and the School of Nursing at the University of Alabama at Birmingham, chairs the COG Nursing Discipline Committee and spoke to Oncology Nursing News® about a structured interventional approach to optimize parent and family education and increase nurses’ satisfaction.

The intervention, which a COG workgroup developed to educate parents after their child receives a diagnosis, follows an 18-item checklist to ensure essential information is taught prior to hospital discharge.

 This checklist addresses topics including diagnosis/treatment, access to care, treatment of adverse events, infection prevention, care of the child, and home medications. Some areas, such as handwashing and taking temperature, require return demonstration.

Education must be patient/family-centered, focused on essential information first, consistent, repeated, structured, paced, and delivered according to the family’s preferred style of learning.

“Early on,” Landier says, “parents tend to be anxious about the logistics of life following diagnosis. They want to know how they’ll handle working, telling the other children, paying the bills, and managing the appointments.” The impact of hearing their child has cancer makes retention of information difficult at this stage.

Posting the COG checklist in the child’s hospital room allows nurses to know at a glance what areas have been taught and to whom, how, and when they were addressed, as well as whether a topic’s final checkoff is complete. This provides transparency, with a list that is easy to use, accessible, and empowering for nurses, as they are always aware of what areas still need to be addressed. The checklist, along with the parent guide and handbook, is available through the COG.

“Nurses are pivotal when it comes to helping families cope,” Landier stated. “They bridge the gaps by providing essential education on complex information in a way the family can best understand. It means so much to families when nurses take the time to translate medical language for them and meet them where they are.”

One of the best ways nurses can build a trusting relationship with parents is to hold space for them to feel how they feel. If they are angry or sad, hold space for that. Amy Haskamp, MSN, RN, PCNS-BC, CHPPN, CPON, clinical nurse specialist for the Pediatric Palliative Care Team at Riley Hospital for Children in Indianapolis, Indiana, and a pediatric faculty member of the End-of-Life Nursing Education Consortium, encourages nurses to align their conversations with parents’ hopes. This is particularly important when a child’s prognosis is poor.

“If the family says they just want their child to stay alive, responding with ‘I will hope for that too’ helps bridge the divide between what parents wish and what nurses know,” Haskamp told 

. She also encourages nurses to use the NURSES mnemonic, which represents “name (the emotion), understand, respect, support, explore, and silence.”

“Communicating with parents about their child’s cancer is not about explaining everything out. It’s about a family who’s experiencing an emotion. Giving more cognitive information is not going to be helpful until emotions are addressed,” Haskamp said.

Haskamp added that acknowledging what parents are experiencing helps them feel supported and respected, which in turn helps them cope with their emotions. “They want to be heard,” she said.

Nurses should tailor conversations with parents to the situation and the family’s communication preferences. If the child has always been involved in conversations about their cancer, abruptly changing this pattern may lead to worry about what is wrong.

Sometimes the family may want help talking to the child. Guiding the conversation by asking and exploring questions often opens the door to deeper communication. Haskamp said nurses must never undersell their role: “They are more valuable than they can imagine.”

1. Key statistics for childhood cancers. American Cancer Society website. 

https://www.cancer.org/cancer/cancer-in-children/key-statistics.html. Updated September 10

2. Withycombe J, Alonzo T, Wilkins-Sanchez M, Hetherington M, Adamson P, Landier W. The Children’s Oncology Group: organization structure, membership, and institutional characteristics. 

2019;36(1):24-34. doi: 10.1177/1043454218810141.

3. Rodgers C, Bertini V, Conway MA, et al. A standardized education checklist for parents of children newly diagnosed with cancer: a report from the Children’s Oncology Group. 

2018;35(4):235-246. doi: 10.1177/1043454218764889.

4. Rodgers CC, Stegenga, K, Withycombe JS, Sachse K, Patterson Kelly K. Processing information after a child’s cancer diagnosis—how parents learn: a report from the Children’s Oncology Group. 

2016;33(6):447-459. doi: 10.1177/1043454216668825.

Oncology nurses are a key part of the cancer care team, but they are also a crucial source of information for a patient's family. 

Providing Essential Education and Support for Parents of Pediatric Patients

Advancements in diagnosis and treatment are improving outcomes for patients with cancer. As a result, more patients are living long after treatment ends, though an efficient algorithm for building the right size and style of care each will need remains elusive.

Over a decade has passed since the Institute of Medicine (IOM) recommended that all patients completing active treatment for cancer receive a survivorship care plan (SCP).

 Many models of survivorship care have since been introduced to address a range of approaches. These include survivorship programs housed in the oncology setting, those led by primary care physicians (PCPs), and multidisciplinary survivorships clinics.

 Also, variations of these models exist and overlap.

More recently, a risk-stratified approach was implemented in England, Northern Ireland, and Australia to help clinicians personalize care pathways.

 Regardless of the model or approach, for certain patients, survivorship care should address health promotion, care coordinations, and the prevention and mitigation of late- and long-term effects of cancer and its treatment, including cardiac toxicity, cognitive changes, and lingering anxiety and/or depression.

As clinicians care for a growing number of cancer survivors, the urgency to identify the most efficient and effective method of survivorship care planning increases. More research is needed to evaluate the impact of survivorship care on patient outcomes and quality of life and determine best practices for streamlining care. Nurses are positioned to influence the future of survivorship care by advocating for and participating in initiatives geared toward bettering care throughout the cancer trajectory—something that is currently difficult to navigate.

“I’m a nurse with a PhD, and I think the system is difficult to navigate,” says Marci Lee Nilsen, PhD, RN, CHPN, assistant professor of acute and tertiary care in the School of Nursing and assistant professor of otolaryngology in School of Medicine at the University of Pittsburgh in Pennsylvania. “It’s overwhelming for patients.”

Survivorship is a distinct phase of living with cancer framed by completion of initial treatment and either recurrence, second cancer, or death.

 When patients require ongoing treatment, providers determine when entering survivorship care makes sense on a case-bycase basis. If patients step away for acute care treatment due to recurrence or second cancer, they return when treatment is once again complete. This journeying back and forth continues as needed. Although the IOM made clear in its 2006 report the importance of providing each patient with an SCP, studies have shown inconsistent implementation of the recommendation. 2 Even a quick review of the information identified for inclusion in SCPs underscores the value for patients and providers alike. Minimally, patients should receive details about tests and results; tumor characteristics; treatment start and stop dates; treatments, including response and toxicities; support services provided; contact information for institutions and providers; and care coordinator information.

Additionally, patients and PCPs should receive a written follow-up plan that summarizes the expected course of recovery and any ongoing therapy; recommended screening/testing/ exams, including schedule and provider; possible aftereffects of treatment, including symptoms; signs and symptoms of recurrence and new cancers; possible psychosocial effects; insurance and financial implications and assistance; lifestyle recommendations; genetic counseling (as appropriate); secondary prevention strategies; follow-up referrals; and information resources.1 Undoubtedly, the time and effort required to compile a comprehensive care plan can be burdensome, relative to the complexity of each patient’s situation and circumstances. Nonetheless, the SCP serves as an invaluable tool for clear, consistent communication, follow-through, and reference, particularly when all recommended information is covered. Improvements are needed to simplify the development of SCPs; remove identified barriers for implementation; and propose practical, actionable standards of practice. LATE AND

Cancer and its treatments take a toll on patients. Although a common (and feared) late effect is development of a recurrence or new cancer, other complications, such as cardiac toxicity— particularly for breast cancer survivors&mdash;and congestive heart failure, atherosclerotic disease, ischemia, hypertension, and myocardial depression, are serious and life-threatening.1 Adhering to recommendations for cardiac screening and monitoring for specific patient populations may mitigate the risk and severity of cardiac effects. Cognitive changes can be particularly frustrating for patients. Often referred to as chemo brain, they include impaired memory and decision making and difficulty concentrating.

Research is inconclusive regarding the root cause of cognitive deficiencies, but their impact on quality of life goals is wide-ranging and can lead to increased distress.1 Informing patients that they may experience difficulties in this area while not causing them undue alarm requires tactfulness and empathy.

Lingering anxiety and depression are not uncommon and should therefore be addressed. Interventions to prevent or minimize their severity begin with awareness and education and may include complementary measures such as aromatherapy and meditation or diet and nutritional modifications. Patients should not be caught off guard by anxiety or depression. Addressing the matter up front and early can help make their occurrence easier to identify and intercept.

The number of possible late and long-term effects of cancer and its treatment seems limitless. The least clinicians should do for their patients is have conversations about the most probable effects and provide as-needed education that is helpful yet not overwhelming.

Differences in care settings often influence or dictate the model of survivorship care. Perhaps the most important aspect involves who directs the care for cancer survivors. The most common yet least formal model begins with oncology-led care, transitioning to PCP-led care when deemed appropriate by the oncology team. Oncologist-led care is likely the least practical, considering that the number of patients living with cancer is estimated to increase from 16.9 million to over 22 million by the year 2030.3 Oncology practices will simply not be able to manage the workload of caring for new patients and patients in survivorship.

PCP-led care has its own limitations and concerns. PCPs are less familiar with the needs of post-treatment cancer patients than oncologists, so issues may arise that are either identified late or treated inappropriately. It’s easy to understand how survivorship care can quickly become complicated, especially when factoring in patient comorbidities such as diabetes, hypertension, obesity, and a host of other diseases. No consensus has been reached about who is best suited to manage the multiplicity of health issues that do or may occur during active treatment and survivorship. Survivorship clinics, which house many services in 1 location, are becoming more popular. Nilsen describes the University of Pittsburgh Medical Center (UPMC) Head & Neck Cancer Survivorship Clinic she helped develop and currently coordinates: Employing an integrative care model, the care team consists of a head and neck surgeon, an audiology assistant, a kinesiologist, a physical therapist, a dentist, and a medical consultant, all of whom provide services in 1 clinic. The workflow is patientcentric and begins with patient completion of a validated, reliable questionnaire to identify problems. Patients are then roomed and, because they are at higher risk of hearing loss, undergo a hearing screening. They will also have an audiogram, wax removal, or hearing aid repair (done at no charge), if indicated.

“If patients cannot hear you, then discussions with them will be problematic,” Nilsen says. While the audiologist works with the patient, the nurse reviews the paperwork. Nilsen then completes a treatment summary, so everyone has an overview of when the patient was treated, tumor site and stage, and type of treatment received. Next, the patient is screened for any swallowing or musculoskeletal problems. A patient who would benefit from physical therapy need not go elsewhere for treatment—the service is readily available at the survivorship clinic. Providing many services under 1 roof simplifies care coordination and helps ensure continuity of care.

Nilsen says the clinic’s success comes from its focus on the patient and collaboration of care, which help address many of the needs faced by head and neck cancer survivors. Some treatments, such as dental care (for which patients may not have insurance coverage), are paid for through grants and fund-raising efforts. Creative problem solving helps make sure patient needs are met.

Other benefits of survivorship clinic models are coordination of care and availability of so many services in 1 place, Nilsen says. This model minimizes the difficulty of navigating a complex healthcare system.

A crucial component, according to Nilsen: communication, particularly in survivorship care. Everyone involved with the patient must have open lines of communication. “It’s important to bring up the issue of survivorship care early,” Nilsen says. “There are so many issues with head and neck cancer. It’s best for patients to be informed, not surprised.”

Although survivor clinics such as the UPMC model provide a convenient and invaluable option, not everyone has access to this type of care, nor is this model needed for all types of cancer, particularly those considered low risk. Another promising approach offering both flexibility and applicability for a range of patients and circumstances is the personalized risk-stratified pathways model.

Deborah Mayer, PhD, RN, AOCN, FAAN, Francis Fox Hill Distinguished Professor in the School of Nursing and director of survivorship at the Lineberger Comprehensive Cancer Center at the University of North Carolina at Chapel Hill, is a recognized champion of cancer and oncology nursing. In 2015, she was awarded the Oncology Nursing Society’s Lifetime Achievement Award for her many contributions to the field. Mayer is a proponent of risk-stratified survivorship care, which begins with differentiating survivors in high-volume groups from those in high-risk groups. She acknowledges that data are missing to recommend who fits the kind of survivorship care they need: “We need a risk-stratified approach because we can’t be all things to all people.” That may be hard for clinicians to hear, but it makes sense.

Mayer says that patients with breast, prostate, and colorectal cancers (high volume) are likely to do relatively well following treatment, whereas those with head and neck cancers (high risk) will likely face a myriad of late and longterm effects unique to this patient population.

Adult survivors of pediatric cancers fall into yet another category. These patients are susceptible to being lost in care as their focus shifts toward college or career goals and away from cancer, even as physical and psychosocial effects remain cause for concern.

Categorizing patients by volume and risk can help providers simplify the care management process while ensuring patients receive needed services and support. This model makes financial sense by improving patient outcomes and controlling cost. Studies conducted after the model was piloted in the United Kingdom showed that 50% to 80% of survivors in the highest- volume group (colorectal, breast, and prostate) were able to self-manage care after treatment.

The basic premise of the model consists of triaging patients according to need and type of provider involvement, or right-sizing care. “If a patient is 20 years out from breast cancer, there is no reason to come to a cancer clinic for follow-up, yet many of them do,” Mayer says. “It’s also emotionally rewarding for the oncologist to see someone is doing well,” Mayer pointed out. Again, flexible, patientfocused care is possible, but the business-asusual model would need to change for this to happen efficiently.

Without question, cancer changes everything. Patients who receive cancer diagnoses will face acclimating to and accepting survivorship care as another facet of what will become their new normal. Clinicians who competently guide patients into and through this phase of care ease the burden.

Although it may come as a surprise to many, Mayer says she believes survivorship care is not new. “There’s nothing special about survivorship care,” she says. “It’s been labeled, but it’s follow-up care. It’s what we’ve been doing all along.”

Hewitt M, Green&#64257;eld S, Stovall E, eds; Committee on Cancer Survivorship: Improving Care and Quality of Life, National Cancer Policy Board. 

From Cancer Patient to Cancer Survivor: Lost in Transition.

 Washington, DC: The National Academies Press; 2006.

Powel LL, Seibert SM. Cancer survivorship, models, and care plans. 

. 2017;52(1):193-209. doi: 10.1016/j.cnur.2016.11.002.

American Cancer Society. Cancer treatment & survivorship facts & figures 2019-2021. cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-treatment-and-survivorship-facts-and-figures/cancer-treatment-and-survivorship-facts-and-figures-2019-2021.pdf. Published 2019. Accessed July 10, 2019.

Mayer DK, Alfano CM. personalized risk-stratified cancer follow-up care: its potential for healthier survivors, happier clinicians, and lower cost. 

 2019;111(5):442-448. doi: 10.1093/jnci/djy232.

Some oncology nurses are leading the improvement of survivorship care, a field that is becoming increasingly important in the world of cancer.

Cancer Survivorship: Right-Sizing Care

Nancy McClung, PhD, RN - Photo credit: Mike Glatzer

What if preventing cancer were as simple as getting a shot in the arm? That is the reality for over 90% of cancers caused by the human papillomavirus (HPV).

 However, statistics from the Centers for Disease Control and Prevention (CDC) reveal that less than 50% of the US population within the targeted age range has received all recommended doses of the HPV vaccine.

 Oncology nurses must stay attuned to the critical vaccination information, including prevalence and prevention, treatment and immunization, and future advances.

HPV infections affect nearly every sexally active person at some point in their life. Although many infections are asymptomatic and resolve without treatment, others are implicated in the 10,800 cases of cervical cancer, 12,900 cases of oropharyngeal cancer, 5900 cases of anal cancer, 3300 cases of vulvar and vaginal cancer, and 900 cases of penile cancer diagnosed in the United States every year. Additionally, about 300,000 new cases of high-grade cervical (precancerous) lesions are identified annually through screening.

 When given before exposure to the virus, the HPV vaccine effectively prevents over 90% of these occurrences. It is the only vaccine currently available for the prevention of cancer.

Nancy McClung, PhD, RN, epidemic intelligence service officer and nurse epidemiologist with the International Center for Immunization and Respiratory Diseases, Office of Infectious Diseases, at the CDC in Atlanta, Georgia, is part of a team involved in policy work and research into the impact of the HPV vaccine in the United States. At the 2019 Annual Epidemic Intelligence Service Conference, she presented the results on the prevalence of HPV infections in female patients in the United States. Since 2006, when the vaccine was introduced, adolescent vaccination-preventable HPV infections have decreased by 86%. For women aged 20 to 24 years, the decline has also been significant, at 71%.

 These numbers reflect steadily increasing vaccination rates, although the HPV vaccine is still given less than other, more established vaccines. In 2013, the team began monitoring HPV vaccine—preventable infections in male patients; they expect to see similarly encouraging results as data become available. The most common HPV-caused cancer in male patients occurs in the oropharynx. “We know HPV causes cancer because we find HPV in all kinds of anogenital cancers, including cervical, anal, penile, vulvar, and vaginal. The virus is detected through biopsy only after becoming cancerous,” McClung said.

Most HPV-caused cancers cannot be detected in the precancerous stage; cervical cancer is the exception and can be detected earlier through screening and subsequently treated. “Parents can prevent cancer in their children by vaccinating them. Providers can prepare and plan for vaccinating adolescents the same day and same time as other routine vaccinations, such as tetanus and meningitis. This vaccine is working. We are confident that it will prevent cancer.”

Recommendations for the HPV vaccine were approved in 2006 for female patients and in 2011 for male patients. Because the vaccine works best before exposure to the virus, parents should have their children vaccinated before they are sexually active. It bears repeating that HPV is a very common virus with a high risk of exposure at some point in an individual’s life. McClung stressed that the vaccine is preventive, not therapeutic; it will not cure the infection or cancer.

Although 3 variations of the HPV vaccine are available, only 1 is currently used in the United States. The earlier quadrivalent vaccine (2006- 2015) protected against HPV types 6 and 11 (anogenital warts) and 16 and 18 (most types of HPV cancers), whereas the 9-valent vaccine (2016-present) protects against the same strains as well as 5 additional types.

The CDC recommends routine HPV vaccination at age 11 or 12 years, although clinicians may start it in children as early as age 9. Two doses are recommended for most people starting before their 15th birthday, with the second dose given 6 to 12 months after the first. Patients require a third dose if the first 2 doses were given less than 5 months apart.

Teens and young adults who start the series between ages 15 and 26, as well as immunocompromised individuals aged 9 to 26 years, should receive 3 doses of the HPV vaccine, with the second dose given 1 to 2 months after the first, followed by the third dose 6 months later. The CDC also recommends HPV vaccination for individuals already sexually active or exposed to HPV to protect against other types of the virus. Vaccinated individuals not only protect themselves from HPV infection but also indirectly protect those who are unvaccinated. This is known as herd protection, and cost-effectiveness models predict that reductions in HPV infections in unvaccinated men and women are likely, given enough numbers of vaccinated individuals.

The HPV vaccine is extremely safe. Adverse reactions are similar to those of other vaccinations, with the most common being pain, redness, and swelling at the injection site and, less frequently, mild fever. The vaccine is available to every child in the United States, and nurses at all levels of care and care settings can be the voice to the public for the HPV vaccine and its role in preventing cancer.

SIPULEUCEL-T AND PROSTATE CANCER TREATMENT

Clinicians are also using vaccines to treat cancer. Sipuleucel-T (Provenge) was approved by the FDA in 2010 as a first-line treatment option for men with metastatic, minimally symptomatic, castrate-resistant prostate cancer. Meredith Morgan, PhD, a nurse practitioner at the University of Michigan’s Cancer Center in Ann Arbor, specializes in genitourinary cancer. She spoke with Oncology Nursing News® recently about the benefits of sipuleucel-T.

“The mechanism of action of this autologous, cellular immunotherapy—though somewhat unknown&mdash;directs the immune system to attack prostate cancer cells,” Morgan said. “Sipuleucel-T does not influence PSA [prostate-specific antigen] levels, and we don’t see a real difference in scans of patients treated with the vaccine, making it challenging to measure its success. What we do know, however, is that patients tend to live an average of 4.1 months longer when treated early. Sipuleucel-T is well tolerated, and adverse reactions are generally mild and short-lived. The vaccine is not useful, however, for patients with end-stage cancer. And although it is quite expensive, the cost of the drug is often covered by insurance.”

Since the introduction of the vaccine in the prostate cancer space, the FDA has approved several alternative oral medication options. Assessing patient appropriateness for sipuleucel-T is important, as other therapeutic treatments may be equally as effective in providing survival benefits. Once a clinician has identified a patient as a candidate for sipuleucel-T, the preparation of their personalized therapy begins.

“The first step takes place in an apheresis center, such as those operated by the Red Cross, where a vein assessment is completed. Patients with inadequate veins will require an implanted port; patients with adequate veins will have a dialysis-type catheter inserted, 1 in each arm. Over a 3- to 4-hour period, blood is removed, immature antigenpresenting cells are collected, and the blood is returned to the patient,” Morgan explained. “The collected cells are shipped to the drug manufacturer’s lab, where a protein [immune cell activator] is added to boost the immune power of the cells. After a 3-day turnaround time, these super white cells are shipped out and courier-delivered to the infusion setting, where they are given the same day,” Morgan added.

The treatment plan comprises 3 rounds of apheresis and infusion. The entire process is time sensitive and requires precise coordination to ensure the drug is delivered and administered within the allotted window. Nurses should instruct patients to drink plenty of water before the apheresis process, avoid caffeine, eat a calcium- rich breakfast, wear clothing with loose-fitting sleeves, and arrange for a ride home, as the blood removal procedure can be exhausting.

Nurses administering the immunotherapy wear standard personal protective equipment and follow the same safety checks as those for other transfusions. Opening the medication box, spiking the drug, and beginning the procedure of infusion must be completed within a tight time frame. Verifying patient information and the expiration date and time requires 2 registered nurses as a safety measure. Adherence to protocols provided by the drug manufacturer is a key responsibility for nurses who are administering the therapy. Infusions are given using primary intravenous tubing with no filter.

Adverse events associated with sipuleucel-T are generally infusion related. Patients are premedicated with acetaminophen and diphenhydramine and instructed to continue taking acetaminophen post infusion as needed for chills, fever, muscle aches, and joint pain. These symptoms are shortlived and much more tolerable than reactions associated with traditional chemotherapy. Some patients, such as those receiving steroid medications or with hematologic disorders, are not candidates for this treatment.

IMMUNIZATION CONSIDERATIONS FOR PATIENTS WITH CANCER

Routine vaccination is also an important consideration for patients with cancer, as some vaccine-preventable diseases may be linked to worse outcomes in this population. The CDC issues routine vaccination recommendations for patients based on age, evidence of immunity, and special criteria, such as immunocompromising conditions.

 Based on the severity of those conditions in patients, clinicians may need to delay vaccinations. Activated vaccines should be given prior to immunotherapy or chemotherapy or following completion of treatment.

Influenza can lead to serious complications in patients with cancer. As such, nurses must stay abreast of current developments regarding flu vaccines to ensure they provide accurate information to their patients about the timing and effectiveness of vaccine administration.

Research, development, and testing of vaccines for the treatment of a variety of cancers are ongoing. These therapies include tumor cell vaccines, antigen vaccines, dendritic cell vaccines, and vector-based vaccines. Vaccine study is under way for common cancers such as glioblastomas and other brain cancers, lymphoma, melanoma, and breast, cervical, colorectal, kidney, lung, pancreatic, and prostate cancers. This is an exciting area of research with the potential to significantly affect oncology nurses’ perception and use of vaccines for patients with cancer. Nurses will be at the forefront of patient education as new treatments and preventive measures become available. As clinical trials move forward, oncology nurses will also be instrumental in guiding patients through the enrollment process and sharing information as it is disseminated throughout the healthcare community. The day may come when preventing a variety of cancers is truly as simple as a getting a shot in the arm—the idea may not be that far-fetched after all.

Why is HPV vaccine important? Centers for Disease Control and Prevention website. 

. Updated March 10, 2017. Accessed May 9, 2019.

HPV vaccination coverage data. Centers for Disease Control and Prevention website. 

. Updated August 23, 2018. Accessed May 9, 2019.

Infographic: screening won’t protect your patients from most HPV cancers. Centers for Disease Control and Prevention website. 

cdc.gov/hpv/hcp/hpv-important/more-than-screening-infographic.html

McClung N. Human papillomavirus prevalence among females in the United States, overall and by race/ethnicity, National Health and Nutrition Examination Survey, 

 -2006 and 2013-2016. Presented at: 68th Annual Epidemic Intelligence Service Conference; April 29-May 2, 2019; Atlanta, GA.

Vaccination schedules & recommendations. Centers for Disease Control and Prevention website. 

cdc.gov/hpv/hcp/schedules-recommendations.html

Malagon T, Laurie C, Franco E. Human papillomavirus vaccination and the role of herd effects in future cancer control planning: a review. 

2018;17(5):395-409. doi: 10.1080/14760584.2018.1471986.

Table 1. Recommended adult immunization schedule for ages 19 years and older, United States, 2019. Centers for Disease Control and Prevention website. 

cdc.gov/vaccines/schedules/hcp/imz/adult.html

. Updated February 5, 2019. Accessed May 10, 2019.

Shah M, Kamboj M. Immunizing cancer patients: which patients? which vaccines? when to give? 

Nurses must stay attuned to the critical vaccination information, including prevalence and prevention, treatment and immunization, and future advances.

Vaccinations Are Changing the Landscape of Cancer Prevention and Treatment

Technology has revolutionized healthcare, making it safer and more accessible than ever. Smart pumps deliver intravenous medications. Electronic health records influence decision support. Remote pharmacists and video conferencing services connect clinicians with resources and information from professionals across the globe. Researchers partner with artificial intelligence programs for developing new drugs, predicting tumor evolution, and distinguishing types of cancer cells. Technology has become an indispensable component of modern healthcare.

Technology has also revolutionized patient access to healthcare tools that can make it easier for people to manage care at home. Conduct a Google search for “cancer apps” and instantly you have many options—care advisers, medication trackers, symptom checkers, support groups, treatment reminders, memory boosters, insomnia busters, meditation guides, and audio diaries are all available with a simple point and click. When it comes to healthcare help, there really is an app for that. Thanks to technology, nurses, researchers, and patients have more options and access than once thought possible.

Along with those technological advances come changes in care delivery. At-home symptom monitoring is rapidly becoming a reality, and for patients with cancer, novel technologies can improve quality of life by putting more power in their hands. As cancer care increasingly takes place in outpatient settings, the complex task of managing the effects of chemotherapy creates a heavy burden for patients. Despite the best efforts of oncology nurses and other clinicians to ensure that patients have the information they need to manage nausea, insomnia, pain, loss of appetite, and other debilitating symptoms, patients frequently end up in the emergency department or are admitted to the hospital because they didn’t know what to do regarding an adverse event or when to act.

Kathi Mooney, PhD, RN, FAAN, is a distinguished professor of nursing at the University of Utah and coleader of the Cancer Control and Population Sciences Program at Huntsman Cancer Institute in Salt Lake City. In a recent interview with 

, she spoke about how one new technology, SymptomCare@Home (SCH), can significantly reduce symptom burden.

“SCH relieves patients of the need to remember instructions they received days or weeks ago. Instead, they’re reminded immediately when reporting a problem, such as nausea,” Mooney said. “They don’t need to know the sequence of what they should do or remember where they put their folder of information. They hear what they need to do when they need to do it.”

The tandem of automated coaching and provider response follows a stepped approach to symptom management, Mooney said. Patients access the system via a web-based platform or mobile application or by telephone. Using a complex algorithm, SCH assesses patient symptoms according to type, severity, and frequency.

Then, based on patient input, the app provides tailored coaching. With nausea, for example, patients are asked if they’ve taken antinausea medication regularly and, if not, why not. In addition to providing on-the-spot instructions, this assessment and coaching technology can help guide discussions in clinic and prompt provider adjustments to plans of care as needed.

Results of a study on the effectiveness of SCH showed that patients in the intervention group had significantly better symptom management than those in the usual care group.

Smartphone apps and other technological advances are helping patients to track and manage their cancer symptoms.

Ellen Rice Tichich, MFA, MSN, RN-BC

Articles

Caring for the Geriatric Patient: What Oncology Nurses Need to Know

Global Oncology Nursing Improves Cancer Care Worldwide

Providing Essential Education and Support for Parents of Pediatric Patients

Cancer Survivorship: Right-Sizing Care

Vaccinations Are Changing the Landscape of Cancer Prevention and Treatment

Novel Technology Helps Patients Manage Symptoms

Recruitment and Retention Efforts Address Oncology Nursing Shortage

Improving Palliative Care Through Education

Lung Cancer and the Young Adult Nonsmoker

To Test or Not to Test? Pros, Cons, and the Promise of Genomics in Prostate Cancer