The American Cancer Society estimates that almost 14.5 million cancer survivors are alive in the United States today. By 2024, the number of survivors will grow to almost 19 million. Many factors contribute to this growing number, including earlier diagnosis, improved treatments, and better follow-up care.

But are cancer survivors getting the specific care they need?

From Cancer Patient to Cancer Survivor: Lost in Transition

 recognizes that the current US healthcare system does not often deliver the comprehensive and coordinated follow-up care that cancer survivors require. The reports calls on providers not only to arrange for surveillance for cancer recurrence but also offer holistic care addressing chronic effects of cancer and treatment side effects, monitoring for and preventing late effects like heart disease, and promoting a healthy lifestyle.

Because nursing has a significant role on the “front lines” of cancer care both in hospitals and ambulatory settings, nurses must serve as a source of knowledge and advocacy for cancer survivors. One specific area that requires attention and research is cardiac health in cancer survivors.

Cancer survivors have nearly an 8-fold increased risk of death due to cardiovascular disease compared with the general population. Potential mechanisms include the cardiotoxic effects of chemotherapy and radiation, and modifiable risk factors related to cardiac health including inactivity, poor diet composition, and excess weight. In addition, cancer survivors experience disease- or treatment-related symptoms that persist post-therapy which are often barriers to an active lifestyle.

Both radiation and chemotherapy can result in cardiotoxicity. Pericardial effusion, pericardial constriction, myocardial dysfunction, and heart failure may be serious clinical conditions encountered among cancer survivors. Effects of chest radiotherapy are manifested as coronary artery disease and valvular dysfunction.

Chest irradiation can also contribute to cardiac dysfunction after the myocardium gets exposed to certain dose levels of radiation. Specific to chemotherapy, anthracyclines (such as doxorubin, epirubicin, liposomal doxorubicin, or mitoxantrone) are major contributors of cardiomyopathy. Unfortunately, these cardiotoxic side effects from treatments are often exacerbated by coexisting conditions like hyperlipidemia and hypertension.

Carolyn Reilly, an assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University, recently completed a study to describe the prevalence of cardiovascular disease in lymphoma survivors.

Participants (N = 31) in this cross-sectional, correlational study were a mean age of 47.6 years; most were males (55%) and white (84%). Participants averaged 5 years since lymphoma treatment. Routine laboratory tests and fasting lipid levels, coronary artery calcification computed tomography, echocardiography, and patient-reported outcomes were measured.

 Subclinical disease was detected in 35% of the sample, with 28.6% of the women having diastolic dysfunction. Women scored lower than men in health-related quality of life measures and had more symptoms (bloating and diarrhea). Of those with subclinical disease, women were more likely to re&shy;port pain, numbness in hands or feet, and shortness of breath.

These results demonstrate the need for assess&shy;ment of symptoms that could uncover subclinical disease and lead to timely referral for follow-up and treatment.

Nurses can promote heart health by teaching their patients about the benefits of exercise. Increasing physical activity can decrease the modifiable cardiac risk factors of inactivity and excess weight.

The best treatment identified to reduce fatigue and to improve psychological distress in cancer survivors is increased physical activity. Regular physical activity prolongs overall survival and dis&shy;ease-free intervals, improves quality of life, mood, fitness, physical function, and decreases fatigue.

More work is needed to determine the best ap&shy;proach to increasing physical activity in cancer sur&shy;vivors. Information is needed to determine the spe&shy;cifics of interventions for cancer survivors including the best type, duration, frequency, and intensity.

A recent Cochrane review of 14 randomized clinical trials of exercise interventions in sedentary cancer survivors

 found that although none achieved an adherence of 75% or greater to the recommended 150 minutes of moderate to strenuous aerobic activ&shy;ity per week, three did achieve 75% adherence to a lower goal, resulting in improved exercise tolerance.

The most successful interventions involved com&shy;ponents such as setting program goals, encouraging practice and self-monitoring, and teaching partic&shy;ipants to use skills learned in supervised exercise environments in other areas of their day-to-day life.

Additional research is needed to determine the best approach to deliver comprehensive and coor&shy;dinated follow-up care for cancer survivors. Assess&shy;ment of cardiac risk is needed in future programs, along with evidence-based interventions to decrease modifiable risk factors. Nurses as researchers, cli&shy;nicians, advocates, and teachers are in a prime posi&shy;tion to lead these efforts. Cancer survivors need our continued care!

Institute of Medicine and National Research Council. 

. Washington, DC: The National Academies Press; 2005.

Reilly C, Esiashvili N, Parashar S, Higgins M. Subclinical cardiovascular disease in lymphoma survivors by gender [published March 23, 2016]. 

Bourke L, Homer KE, Thaha MA, et al. Interven&shy;tions for promoting habitual exercise in people living with and beyond cancer. 

Articles

The American Cancer Society estimates that almost 14.5 million cancer survivors are alive in the United States today. By 2024, the number of survivors will grow to almost 19 million.

Heart Health and Cancer Survivors

For the over 1.5 million individuals expected to be diagnosed with cancer in 2015, pain can be a significant problem.

 Pain can seriously affect quality of life and interfere with all daily activities. Cancer pain is reported in about one third of those completing treatment and two thirds of those undergoing treatment, as well as two thirds of those with advanced disease.

Studies indicate that over 40% of patients with cancer do not get adequate relief from their pain.

 Under treatment of pain has significant adverse effects and is associated with serious patient distress and depression.

Effective pain treatments exist. Proper application of the World Health Organization Pain Relief Ladder allows 80% to 90% of patients to find relief from pain, regardless of care setting or social and/or cultural environment.

 This three-step "ladder" includes the prompt oral administration of drugs in order (non-opioids; then, as needed, mild opioids; then strong opioids (eg, morphine), until the patient is pain free. To maintain freedom from pain, drugs should be given around the clock at a specific time interval depending on the drug, rather than on demand or PRN. For many with severe cancer pain, around-the-clock with long-acting opiates is the preferred treatment.

Unfortunately African Americans experience a disproportionate burden of cancer pain and suffer worse treatment outcomes.

 Although fundamentally important, the explanations for these disparities in cancer pain are not fully known; most likely an interplay between individual, social, and system-level factors contribute to African Americans with cancer pain not getting adequate relief.

Numerous individual factors may affect a person’s ability to get relief from pain. African Americans with cancer pain have expressed reluctance to verbalize pain or to seek help due to beliefs of stoicism, concerns about possible addiction and drug tolerance, fears of side effects, and a desire only to take medications when pain is severe.

Counterproductive beliefs about pain include such notions as, pain is an expected part of life; grin and bear it; pain is God’s will; people that succumb to pain are weak.

The role of social support as it relates to pain relief can both positively and negatively influence a person to take pain medication when in pain. Attitudes about pain and pain treatment may influence both the individual experiencing pain and their social network, especially in the the context of the current national dialogue about drug abuse and the over-prescription of opioids.

Nearly 15,000 people die each year of overdoses involving prescription painkillers, the CDC reports.

Opiate abuse widely discussed in the medical community and lay media, and this likely influences not only individuals who have been prescribed medications for cancer pain, but also the individuals who support them. Despite—or perhaps because of&mdash;these influences, cancer patients often underuse prescribed opiates rather than overuse these medicines.

Systemic barriers to pain relief for minorities have been identified.

 Regardless of age or socioeconomic status, African Americans are less likely than Whites to receive analgesic medication for pain. Primary providers are more likely to underestimate pain intensity in African Americans than in other ethic groups. Pharmacies located in minority neighborhoods are less likely to carry sufficient prescription analgesics than those located in white neighborhoods. Compared with white patients, black patients were more likely to have more referrals for substance abuse assessment, fewer referrals to a pain specialist and increased drug urine tests.

These alarming examples of bias in our healthcare system impact cancer patients daily. Care of pain does not occur in a vacuum but in a context that includes social and system- level influences (family, friends, neighbors, church community, and healthcare systems). Many avenues exist to improve cancer pain relief for minorities, and the role of nurses is a great place to start.

Nurses must use their assessment skills to assess cancer pain in all individuals and partner with patients to help them achieve pain relief. The first step in building this partnership is to ask individuals to describe how they have managed their pain through self-management strategies.

In a recently published qualitative study of advanced cancer patients,

individuals reported the use of many nonpharmacologic strategies to manage pain. Study participants adjusted the speed of their activities or type of activities in search of pain relief. Despite not feeling well, participants needed to continue to care for themselves and their family and plan out their day. Many changed the activities they participated in, sometimes eliminating activities or trying new activities. Most participants spoke of adjusting their diet in order to manage pain.

As well as self-management strategies individuals use to treat pain, patients with cancer pain are often expected to manage complex pain medication regimens. Nurses need to examine the complexity of these medicine regimens frequently. With prescription medications, healthcare providers write the order, but the patient has the responsibility of taking the medications and often adjusts the medications to suit their needs. Pain medication adjustments included differentiating the type, dose, and timing of the medication. In the study of advanced cancer patients, participants took medications for pain, but also for cough, sleep, anorexia, wheezing, insomnia, constipation, nausea, high blood pressure, neuropathy, blood clots, depression, and anxiety and as part of their cancer treatment. All of these medications required education which most often is provided by nurses. The decisions that patients make as they manage complex medication regimens need to be examined further.

Understanding the barriers to symptom relief for all individuals is important. Additional barriers may exist for African Americans and other minorities at the individual, social, and system level. Nurses have a great opportunity to assist patients in working through these barriers with the end result of improved pain relief for all. 

 American Cancer Society. Cancer Facts & Figures 2015. Atlanta: American Cancer Society; 2015.

van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, et al. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol. 2007;18(9):1437-1449.

Deandrea S, Montanari M, Moja L, Apolone G. Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol. 2008;19(12):1985-1991.

 World Health Organization. WHO's Pain Ladder. http://www.who.int/cancer/palliative/painladder/. Accessed August 18, 2015.

Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: The National Academic Press; 2011.

Anderson KO, Richman SP, Hurley J, Palos G, et al. Cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control. Cancer. 2002;94(8):2295-2304.

 Centers of Disease Control and Prevention. Vital Signs: Prescription Painkiller Overdoses in the US. http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html. Accessed August 18, 2015.

Meghani SH, Thompson AM, Chittams J, et al. Adherence to analgesics for cancer pain: a comparative study of African Americans and whites using an electronic monitoring device. J Pain. 2015;16(9):825-835.

National Institute of Neurological Disorders and Stroke. Disparities in Pain Care. http://painconsortium.nih.gov/News_Other_Resources/dpc.pdf. Accessed on August 17, 2015.

Yeager KA, Sterk CE, Quest TE, DiIorio C, Vena C, Bauer-Wu S. Managing one's symptoms: a qualitative study of low-income African Americans with advanced cancer [published online ahead of print June 20, 2015]. Cancer Nurs.

Cancer Pain-Is Relief in Sight for All Cancer Patients? 

Once a terminal illness, HIV is now considered a chronic disease due to the advances in highly active antiretroviral treatment (HAART). Today, individuals infected with HIV often manage comorbidities, including cancer, with their HIV disease.

 During the pre-HAART era, individuals infected with HIV were at significant risk for three types of AIDS-defining cancers—Kaposi’s sarcoma, non-Hodgkin lymphoma, and cervical cancer.

Due to the advancements in treatment and an aging HIV population, HIV-infected individuals are less likely to die from opportunistic infections but now face a growing problem of non—AIDS-defining cancers, particularly Human Papillomavirus (HPV)–related cancers.

HPV is one of the most common sexually transmitted infections in the United States and includes a group of more than 150 related viruses. There are many subtypes of HPV, but the one most likely to cause anal cancer is HPV-16. HPV-16, as well as HPV-18, HPV-31, HPV-33, HPV-45, and some others are considered high-risk types of HPV because they are strongly linked to cancer.

These HPV subtypes can also cause cancers of the cervix, vagina, and vulva in women, as well as cancer of the penis in men, and throat cancer in both women and men. HPV is passed from one person to another during skin-to-skin contact with an infected area of the body. Infection with HPV is common, and in most cases the body can clear the infection on its own. But in some people, like those with HIV, the HPV infection does not clear and is persistent. Persistent infection, especially with high-risk HPV types, can eventually cause certain cancers, including anal cancer.

The increased prevalence and persistence of HPV infections in the HIV-infected population has contributed to increased incidence of anal cancers. Similar to cervical cancer, persistent HPV infection is a significant cause of anal precancerous lesions and anal cancer in HIV-infected individuals.

Immunosuppression plays a significant role in the high prevalence and persistence of HPV infections seen in HIV-infected individuals. Individuals living with HIV not only have an increased risk of acquiring a HPV infection, but also are more likely to have persistent HPV-induced anal squamous intraepithelial lesions.

These lesions can progress to cancer. Among cancer sites associated with HPV infection, anal cancer has the highest incidence rate and occurs at an even greater rate among those infected with HIV than the general population. HIV-infected individuals are 28 times more likely than the general population to be diagnosed with anal cancer. Mortality and morbidity from anal cancer among HIV-infected individuals is also substantial. The 5-year survival rates range from 47% to 60%.

The goal of a cancer screening program is to capture and treat early signs of precancerous lesions before progression to cancer. The success of a national cervical screening program over the last five decades has led to drastic decreases in cervical cancer mortality and morbidity in the general population.

Analogous to the cervix, the anal canal has a transformation zone where columnar epithelial cells transition to squamous epithelia. This zone is vulnerable to the development of precancerous lesions from HPV infection.

Anal pap testing involves collecting cells from the anal canal for cytological examination. All abnormal anal pap cytology, regardless of grade, is recommended to be followed up by anoscopy and biopsy of suspected precancerous lesions for histologic confirmation. High resolution anoscopy is important in identifying areas that require treatment in efforts to prevent progression to anal cancer. Unfortunately, research-based screening guidelines for anal cancer are not available.

Jessica Wells, PhD, RN, is working to better understand how to decrease the personal and clinical burden of anal cancer in persons living with HIV. Wells and colleagues conducted an integrated review of recommendations and guidelines for anal cancer screening to provide a guide to inform healthcare clinicians.

This review found that no formal national or international guidelines exist for routine screening of anal cancer for HIV-infected individuals. To date, no randomized control trial has provided strong evidence supporting efficaciousness and effectiveness of an anal cancer screening program. Wells reviewed and synthesized screening recommendations for HIV-infected individuals from seven international, national, and statebased reports. These guidelines based on expert opinion suggest that anal cancer screening may be effective in decreasing the incidence of anal cancer. This review highlights the need for further research to define standard of care for anal cancer screening in HIV-infected persons, a vulnerable group that will benefit from an anal cancer screening program.

Given the heightened incidence in this population, it is imperative that clinicians provide or connect the patient to cancer prevention resources, including HPV vaccination when indicated. From the review of recommended guidelines, it is suggested that all HIV-infected patients should, at a minimum, have a visual inspection and digital rectal exam included in their annual physical exams. Annual or biennial anal pap testing is strongly recommended, especially for those high-risk individuals living with HIV. 

These recommendations are given under the assumption that these patients are managed at a high-resource setting where trained and skilled clinicians, cytology, pathology, high resolution anoscopy, biopsy, and necessary treatment are available.

No doubt more research and education are needed to combat anal cancer, especially for those HIV-infected individuals who experience such a high burden of disease. Future efforts must focus on screening studies to provide clear directions for cancer prevention in this population to combat the rising rates of anal cancer.

		Darragh TM, Winkler B. Anal cancer and cervical cancer screening: key differences. Cancer Cytopathol. Feb 25 2011;119(1):5-19.

		Shiels M, Cole S, Kirk G, Poole C. A Meta-Analysis of the Incidence of Non-AIDS Cancers in HIV-Infected Individuals. J Acquir Immune Defic Syndr. 2009;52(5):611-622.

		Palefsky JM, Holly EA, Gonzales J, et al. Detection of human papillomavirus DNA in anal intraepithelial neoplasia and anal cancer. Cancer Res. 1991;51(3):1014-1019.

		Ahdieh L, Klein RS, Burk R, et al. Prevalence, incidence, and type-specific persistence of human papillomavirus in human immunodeficiency virus (HIV)-positive and HIV-negative women. J Infect Dis. 2001;184(6):682-690.

		Frisch M, Biggar RJ, Goedert JJ. Human papillomavirus-associated cancers in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome. J Natl Cancer Inst. 2000;92(18):1500-1510.

		Chiao EY, Giordano TP, Richardson P, El-Serag HB. Human immunodeficiency virus-associated squamous cell cancer of the anus: epidemiology and outcomes in the highly active antiretroviral therapy era. J Clin Oncol. 2008:26(3):474-479.

		Wells JS, Holstad MM, Thomas T, Bruner DW. An integrative review of guidelines for anal cancer screening in HIV-infected persons. AIDS Patient Care STDs. 2014;28(7):350-357.

Once a terminal illness, HIV is now considered a chronic disease due to the advances in highly active antiretroviral treatment (HAART). 

Anal Cancer in HIV-Infected Individuals

Fatigue is a very distressing symptom experienced by most individuals with cancer.

This symptom has deleterious effects on many aspects of quality of life including physical, psychological, and social well-being. When an individual has fatigue, it can limit his or her ability to function at home and at work, to socialize, and to participate in previously enjoyable activities.

In comparison to the fatigue experienced by healthy individuals, fatigue experienced by cancer patients is different in that it is often not alleviated by rest or sleep.

 Despite the negative impact of cancer-related fatigue, in general it is underreported by patients and underestimated by providers. One challenge in the assessment and treatment of this symptom is the lack of knowledge about fatigue, specifically the mechanism underlying fatigue.

The cause of cancer-related fatigue is complex and multidimensional, involving many potentially contributing elements. These include tumor-related factors and comorbid medical/ psychological conditions and also side effects associated with cancer treatment and other medications.

 Some of the biologic mechanisms that have been investigated include anemia, cytokine dysregulation, hypothalamic—pituitary–adrenal axis dysregulation, 5-hydroxytryptophan neurotransmitter dysregulation, and alterations in adenosine triphosphate and muscle metabolism. The process that has received the most attention is the dysregulation of cytokines, with a focus on proinflammatory cytokines.

The connection between inflammation and fatigue comes from animal studies where inflammatory cytokines can signal central nervous system (CNS) changes and produce fatigue and other symptoms. Investigators have proposed that tumors and the treatments used to treat them can activate the proinflammatory cytokine network, leading to symptoms of fatigue via cytokine signaling in the CNS.

The inflammatory response can persist long after treatment completion. Studies conducted with cancer patients before treatment, during treatment, and after treatment have shown associations between fatigue and inflammatory markers, although results have not been consistent.

 In order to learn more about this important association, longitudinal studies are needed.

Canhua Xiao, PhD, RN, a research assistant professor at Nell Hodgson Woodruff School of Nursing at Emory University is currently studying the link between fatigue and inflammation in patients with head and neck cancer receiving radiotherapy. Patients with head and neck cancer typically receive radiation treatment and have particularly high rates of fatigue which often lasts after therapy is complete. Her study seeks to clarify and broaden the understanding of the association of fatigue with pro- and anti-inflammatory signaling. In addition, this study investigates genetic mechanisms with a longitudinal descriptive design. Patients receiving radiation for head and neck cancer are followed from before radiation therapy begins to 1 year post radiation therapy. Xiao’s work is motivated by the hope that understanding the biologic mechanisms of fatigue will be the key to its successful management and perhaps also will benefit other related symptoms.

Until the mechanisms of fatigue are better understood, clinicians should concentrate on available resources. The National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology recommend that all cancer patients be screened for fatigue at their initial clinical visit, and then regularly during and after their cancer treatment has been completed.

 One unique challenge in the assessment of fatigue is that a patient’s perception of fatigue can change before, during, and after treatment, meaning that fatigue scores cannot be compared throughout the treatment continuum.

Once it has been determined that a patient is experiencing fatigue, the next step is to determine if there are any potentially treatable factors that could have contributed to the development of cancer-related fatigue, such as anemia, pain, emotional distress, sleep disturbance, malnutrition, medication side effects, and comorbidities.

However, even after treating these conditions, a significant proportion of cancer patients will continue to experience fatigue. For these individuals, intervention with additional therapeutic modalities may be required.

Pharmaceutical agents to treat fatigue have been studied but none have proved to reliably prevent or treat this symptom.

 A variety of nonpharmacologic interventions have shown potentially beneficial effects including physical activity, psychosocial support, and mind—body treatments.

Specific interventions such as cognitive-behavior approaches, acupuncture, mindfulness-based yoga, and biofield therapies have shown promise but need further investigation.3 Because fatigue is such a distressing symptom, clinicians and researchers must continue to work to understand the mechanisms behind this challenging symptom and determine the most effective treatments.

		Koornstra RH, Peters M, Donofrio S, et al. Management of fatigue in patients with cancer—a practical overview. Cancer Treat Rev. 2014;40(6):791- 799.

		Mustian KM, Morrow GR, Carroll JK, et al. Integrative nonpharmacologic behavioral interventions for the management of cancer-related fatigue. Oncologist. 2007;12(suppl 1):52-67.

		Bower JE. Cancer-related fatigue-mechanisms, risk factors, and treatments [published online August 12, 2014]. Nat Rev Clin Oncol.

		Mock V, Atkinson A, Barsevick A, et al. NCCN Practice Guidelines for Cancer-Related Fatigue. Oncology (Williston Park). 2000;14(11A):151-161.

		Minton O, Richardson A, Sharpe M, et al. Drug therapy for the management of cancer-related fatigue. Cochrane Database Syst Rev. 2010;7(7):CD006704.

Cancer-Related Fatigue-Complex, Multidimensional, and Challenging to Treat

With the aging of the US population, the number of seriously ill patients with complex conditions is expected to rise.

These demands on the healthcare system require consideration of new care models to improve coordination, continuity, access, and quality of care. Palliative care is a model of care that has been shown to improve patient satisfaction and reduce the use of acute care services,

 expanding traditional disease-model medical treatments to include the goals of enhancing quality of life for patient and family, optimizing function, and helping with decision-making. It is both a philosophy of care and an organized, highly structured system for delivering care.

The model includes effective management of pain and other distressing symptoms, while integrating psychosocial and spiritual care according to patient/family needs, values, beliefs, and culture(s). Evaluation and treatment is comprehensive and patient-centered, with a focus on the central role of the family in decision-making.

Palliative care affirms life by supporting the patient and family’s goals for the future, including their hopes for cure or life prolongation, as well as their hopes for peace and dignity throughout the course of illness, including the dying process and death.

	Availability of Palliative Care Services

The need for additional palliative care services is expected to increase as the public becomes more aware of its benefits. Recent research by the polling firm Public Opinion Strategies reveals that even for those individuals who are unfamiliar with palliative care, once they understand what it is, 92% report they would be highly likely to consider palliative care for themselves or their families if they had a serious illness.

Fortunately there has been significant growth in the number of palliative care programs over the past decade, but much work is still needed. Much heterogeneity remains in the infrastructure and delivery of palliative care in US cancer centers. Many of these programs are limited to providing inpatient consultation services, and only a few centers have a palliative care unit. Fewer than half of cancer centers offer palliative care outpatient services, which are key because of their potential to promote early access to integrated care.

With the increasing need for palliative care services, advanced practice nurses (APRNs) are well suited to play a pivotal role in this area. APRNs who have specialty preparation in palliative care through education and/or clinical practice function as palliative care experts in the clinical specialist or nurse practitioner roles.

 Certification as Advanced Practice Hospice and Palliative Nurse (ACHPN®) is available through the National Board for Certification of Hospice and Palliative Nurses. The value of the advanced practice palliative nursing role extends beyond specialized and expanded knowledge, critical thinking, and evidence-based practice to enhanced communication skills that facilitate direct patient care through informed decision-making, patient and family education, and psychosocial-spiritual care. The presence of APRNs in diverse care settings broadens access to palliative care.

In addition, palliative care offers an ideal setting for nursing leaders. Nurses have the communication skills necessary to engender trust and draw patients and their families into a partnership of care. Their commitment to quality and safety motivates them to continuously improve the care they provide and make valuable contributions to the interdisciplinary team.

With an investment from the Helene Fuld Health Trust, Emory’s Nell Hodgson Woodruff School of Nursing, in collaboration with the Emory Palliative Care Center, has launched the Fuld Palliative Care Fellowship program to develop nurse leaders in palliative care, an emerging—and necessary&mdash; clinical paradigm. These specialized nurse leaders will be prepared to work interprofessionally to ensure high-quality outcomes for seriously and chronically ill patients and their families, develop new models of care, and shape public discourse and policy.

Situated in a fully interdisciplinary environment, this intensive, leadership-focused program augments the Accelerated Bachelor of Science in Nursing/Master of Science in nursing program (ABSN-MSN) curriculum with mentor-directed projects, consultations with palliative care leaders, simulations, certifications, and other targeted learning opportunities. Fellows will work in partnership with more than 30 palliative care clinicians in Emory’s nationally recognized Palliative Care Center. The school of nursing brings faculty expertise in cancer care, caregiver research, gerontology, HIV-AIDS, chronic disease management, systems development, and religion and spirituality to the partnership. Fellows will be fully prepared to step immediately into palliative care nursing positions and to quickly assume leadership positions to direct this emerging field.

“The Fuld Palliative Care Fellowship program is vitally important to preparing our students to be clinical leaders in delivering palliative care,” says Carolyn Clevenger, Clinical Associate Professor, Nell Hodgson Woodruff School of Nursing and coordinator of this program. “This fellowship program will serve as a national model for preparing nurses to be leaders in specialized areas. Advanced practice nurses are key members of palliative care teams, and the specialized training offered in this program will only increase APRN contribution to high-quality care to patients in this important setting.”

As our population ages and our healthcare system changes, nurses can serve in many roles to fill gaps and provide excellent care.

			Deitrick LM, Rockwell EH, Gratz N, et al. Delivering specialized palliative care in the community: a new role for nurse practitioners. 

			Center to Advance Palliative Care. Get Palliative Care for Policymakers. http://www.getpalliativecare.org/resources/policymakers/2014. Accessed February 26, 2014.

			Hui D, Elsayem A, De la Cruz M, et al. Availability and integration of palliative care at US cancer centers. 

			Meier DE, Beresford L. Advanced practice nurses in palliative care: a pivotal role and perspective. 

The Role of Advanced Practice Nursing in Palliative Care

Depression in cancer patients often goes unrecognized. Depression can be related to cancer-related factors, cancer treatment-related factors, underlying psychiatric history, and social factors. Some groups are particularly vulnerable, such as cancer patients with advanced disease. Depression prevalence estimates vary, depending on how it is assessed, and range from 5% to 16% in outpatients, 4% to 14% in inpatients, 4% to 11% in mixed outpatient and inpatient samples, and 7% to 49% in palliative care.

Certain types of cancer are also associated with an increased occurrence of depression. For instance, patients with lung, hematologic, and gynecologic cancers show higher rates of psychological distress when compared with other cancer types. In general, women report more depression than men. Younger age is associated with higher rates of depression.

 Clinicians working with individuals with cancer recognize that depression is sometimes undiagnosed and untreated. Fortunately, opportunities to improve screening are available.

Approximately half of all new cancer patients receive radiation therapy (RT), which is usually delivered on an outpatient basis through cancer treatment centers on a Monday-to-Friday schedule over 2-8 weeks. This setting provides a valuable opportunity for screening and intervening for psychological distress, but screening procedures must be accurate and time-efficient. Prompt recognition and effective treatment of depression are of critical importance for improving the cancer patient’s quality of life, and possibly improving treatment adherence. Using screening tools and raising awareness about depression is an important step.

Cancer patients receiving RT who are potentially suffering from depression can be effectively identified by a two-item questionnaire, according to research recently presented at the 55th Annual Meeting of the American Society for Radiation Oncology.

 The Radiation Oncology Therapy Group (RTOG) Community Clinical Oncology Program (CCOP)-supported multi-institutional study screened 455 patients receiving radiation treatment at 37 centers around the United States. Participants in the study were seeking treatment for breast cancer (45%); GI cancer (11%); lung cancer (10%); gynecologic cancer (6%); or other cancers (27%). Sixty-six percent of the patients in the trial (298) were women.

Depression screenings were performed before or within 2 weeks of treatment of the initial cancer diagnosis. The screening forms included the single-item National Comprehensive Cancer Network-Distress Thermometer (NCCN-DT); the Hopkins Symptom Checklist (HSCL-25); and the nine-item Patient Health Questionnaire (PHQ- 9), which includes Patient Health Questionnaire-2 (PHQ-2) as its first two questions. All of the study participants answered the screening questionnaires with 100% completion.

Patients received the PHQ-9 and were asked if, within the past 2 weeks, they had “little interest or pleasure in doing things,” or if they were “feeling down, depressed or hopeless.” It was discovered that patients’ responses to these two questions (the PHQ-2) were as useful in identifying depression as results from the entire PHQ-9, and were more indicative of depression than results from the NCCN-DT.

Seventy-five patients (16%) in the study screened positively for depressive symptoms on the PHQ-9. The PHQ9 and PHQ-2 had similar accuracy in detecting patient-reported depression and were superior to the HLSC-25 and the NCCN-DT. Patients who screened positive for self-reported depressive symptoms were administered the Structured Clinical Interview for DSM-IV (SCID) Mood Disorder modules by trained clinical psychologists by telephone. Among those who screened positive on the PHQ-9, 20% (n = 14) met SCID criteria for major depression. Overall, the prevalence of major depression was 3% in this sample. The study determined that screening in an RT setting was well-received by patients and feasible. In addition, of the RT facilities included in the study, 68% offer mental health services.

The PHQ-2, comprising the first two items of the PHQ-9, inquires about the degree to which an individual has experienced depressed mood and anhedonia over the past 2 weeks. Its purpose is not to establish final diagnosis or to monitor depression severity, but rather to screen for depression. Patients who screen positive should be further evaluated with the PHQ-9 and/or SCID to determine whether they meet criteria for a depressive disorder.

“Asking cancer patients about depression should be part of every cancer nurse’s practice,” said Deborah Bruner, RN, PhD, FAAN. “The ability of a simple and effective two-question survey to effectively screen for depression will hopefully prompt more nurses to screen for depression and refer patients in need of mental health services.” Bruner is senior author of the study and Professor at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, Georgia, where she holds the Robert W. Woodruff Chair in Nursing. She is also the Associate Director of Outcomes Research at the Winship Cancer Institute of Emory University, and has worked for over two decades with RTOG with a focus on incorporating patientreported outcomes into national clinical trials.

			Walker J, Holm Hansen C, Martin P, et al. Prevalence of depression in adults with cancer: a systematic review. 

			Linden W, Vodermaier A, Mackenzie R, Greig D. Anxiety and depression after cancer diagnosis: prevalence rates by cancer type, gender, and age. 

			Small W, Pugh S, Wagner L, et al. RTOG 0841: Two-Item Questionnaire Effectively Screens for Depression in Cancer Patients Receiving Radiotherapy. Presented at: American Society for Radiation Oncology 2013 Annual Meeting; September 22-25, 2013; Atlanta, Georgia.

			American Psychological Association. Patient Health Questionnaire. http://www.apa.org/pi/about/publications/caregivers/practicesettings/ assessment/tools/patient-health.aspx. Accessed October 24, 2013.

Depression in cancer patients often goes unrecognized. Depression can be related to cancer-related factors, cancer treatment-related factors, underlying psychiatric history, and social factors. 

Screening for Depression in Patients Receiving Radiation Therapy

	Oncology nurses have a great opportunity to prevent cancer—not just treat it! Media outlets recently reported Michael Douglas’ diagnosis of throat cancer and his statement that human papillomavirus virus (HPV) infection caused his cancer. Oncology nurses can lead the way in efforts to protect the next generation from this type of cancer if they know the facts about HPV vaccination for both girls and boys.

	HPV is the most commonly acquired sexually transmitted infection (STI) in the United States for individuals aged 16 to 24, according to the Centers for Disease Control and Prevention (CDC). It is so common that at least 50% of sexually active men and women acquire this infection at some point in their lives. Unlike many other STIs, HPV can be spread through skin-to-skin contact during sexual play as well as through all types of intercourse.

	Most people with HPV do not develop symptoms or health problems, so they may not even know they have the infection. In 90% of cases, the body’s immune system clears HPV naturally within 2 years. However, four of the 40 HPV strains have been linked with cervical cancer. Chronic HPV infection of one specific subtype (DNA subtype 16) has been associated with cervical cancer and cancers of the mouth, throat, head, and neck.

	HPV-related cancers can be prevented through HPV vaccination, which is approved for both men and women. The effectiveness of the HPV vaccination for females has recently been shown to be better than expected.

 However, HPV infection is not just a concern for women. HPV currently is estimated to infect young men 20 years of age and older at rates between 65% and 93% in highrisk populations and up to 45% among lower-risk populations.

	Unfortunately, the benefit of the HPV vaccine in boys is often overlooked by the initial focus and marketing of the HPV vaccine as a means to prevent cervical cancer. Vaccinating boys and men aged 9-26 years can prevent more than 40,000 cancer-related deaths over the next century, while saving $25,700 per quality-adjusted life-year.

 Unfortunately, despite the usefulness of the vaccine in preventing HPV-related cancers in men, barriers to HPV vaccination still persist.

	To increase vaccination rates for boys, nurses can use family-centered strategies to increase parents’ knowledge of HPV vaccination,

 including awareness of the new HPV immunization guidelines from the Advisory Committee on Immunization Practice (ACIP) at the CDC. These guidelines recommend three doses over 6 months, with the second dose given 1-2 months after the first, and the third dose given 6 months after the first dose for boys and girls aged 11 or 12 years old.

 It is also critical to establish parental awareness of the pathology associated with HPV, including the increasing rates of mouth, head, and neck cancers secondary to HPV infection.

	In order to increase vaccination of adolescent males, all adults—and especially men, fathers, and father figures&mdash;must understand that HPV infection and related HPV cancers are not just “women’s diseases.” The HPV vaccine is just as important for the future health of a boy as it is for a girl. In addition, studies show that HPV vaccination does not promote sexual promiscuity as many people have thought or feared&mdash;an important point to include in patient education.

	The Nell Hodgson Woodruff School of Nursing at Emory University is studying how to break down barriers to vaccination, especially in hardto- reach populations such as families living in rural areas. Assistant professor Tami Thomas has been conducting cancer prevention research in rural communities with a focus on a communitybased, participatory approach. Since 2008, she has engaged parents, pastors, teachers, and community leaders to understand why parents choose to vaccinate their children with the HPV vaccine. Her next step includes development of a culturally specific intervention to increase vaccination rates.

	Oncology nurses will no longer just be treating HPV-related cancers, but instead working to prevent cancer. All nurses have a role in informing parents that HPV vaccination can prevent cancers for both girls and boys.

				Markowitz LE, Hariri S, Lin C, et al. Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, National Health and Nutrition Examination Surveys, 2003-2010. 

				Schiller JT, Day PM, Kines RC. Current understanding of the mechanism of HPV infection. 

				Thomas TL, Snell S. Vaccinate boys with the HPV vaccine? Really? 

				Centers for Disease Control and Prevention. Recommendations on the use of quadrivalent human papillomavirus vaccine in males—Advisory Committee on Immunization Practices (ACIP). 

				Thomas TL, Strickland OL, DiClemente R, Higgins M, Haber M. Rural African American parents’ knowledge and decisions about human papillomavirus vaccination. 

Oncology nurses can lead the way in efforts to protect the next generation from this type of cancer if they know the facts about HPV vaccination for both girls and boys

Katherine Yeager, PhD, RN