Although a recent Gallup poll found the number of Americans who identify as lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) has doubled over the past 10 years, recent studies indicate these patients continue to face health care barriers, including disparities in oncology risk and treatment.

“Unfortunately, there are still many gaps in the cancer care continuum, starting with prevention and early detection,” Diego Rodriguez, MSN, RN, OCN, senior regional nursing director at City of Hope in Duarte, California, said in an interview with 

. “LGBTQ+ patients may skip regular cancer screenings because they don’t feel welcome at certain medical facilities, especially where staff haven’t received LGBTQ+ cultural competency training. This can lead to patients being diagnosed with cancer at a later stage and limiting their treatment options.” 

As frontline caregivers, oncology nurses can improve care for LGBTQ+ patients with cancer by advocating for patient-centered treatment and creating a welcoming environment for patients and their loved ones, Rodriguez said. “By treating each patient as a unique individual with intrinsic value and dignity, oncology nurses can best serve as advocates for their LGBTQ+ patients,” Rodriguez said.

Nursing students typically do not learn about LGBTQ+ health disparities or receive cultural competency training in nursing school. One study found that 2.12 hours is the average time spent on LGBTQ+ issues in the nursing school curriculum.

“Without the proper training and education, nurses and other health care providers can face challenges in caring for patients in the LGBTQ+ community,” Rodriguez said. “We train our nurses on inclusive practices and understand that everyone has unconscious bias that needs to be addressed.” In addition, Rodriguez said all City of Hope staff wear badge cards stating that the medical center is LGBTQ+ friendly so patients know they are welcome.  Because many LGBTQ+ individuals form strong “families of choice” beyond their families of origin, Rodriguez said inclusive care should extend to each patient’s loved ones.

“We always include the patient’s companion/advocates in important conversations and ask for relationships to avoid making assumptions,” Rodriguez said. “I encourage patients to talk about the individuals they believe will best support them in their cancer journey and to have these preferences documented with health providers. Normalizing interactions with our patients, regardless of their sexual orientation or gender identity, should always be a priority.”

To educate nurses and other health care providers about topics such as inclusivity, biases, and preferred pronouns, the Human Rights Campaign and its partnering organizations offer more than 60 training options free to staff of Healthcare Equality Index participating facilities. The trainings include interactive courses and recorded webinars and offer continuing education credits. Oncology nurses also can seek additional training on their own (

Rodriguez noted that City of Hope is among 496 health care facilities presented this year with a LGBTQ+ Healthcare Equality Leader designation from the Human Rights Campaign Foundation. This is the sixth year that City of Hope has received this designation. The Healthcare Equality Index is the national LGBTQ+ benchmarking tool that evaluates health care facilities’ policies and practices related to employees, visitors, and LGBTQ+ patients. 

“We achieved this distinction because of our extensive activities to sustain and nurture an inclusive and diverse workplace for both our patients and staff,” Rodriguez said. “For patients, our efforts included adding sexual orientation and gender identity questions into patient intake forms, developing new patient care policies for treating transgender and gender-nonconforming patients, training leaders in cultural awareness, updating our patient information with nondiscriminatory language, designating ‘all gender’ restrooms, and providing a care navigator for LGBTQ+ patients.”

Although positive strides have been made in caring for LGBTQ+ patients, Lawrence Marsco, MSN, RN, OCN, senior director of nursing at Huntsman Cancer Institute’s Cancer Hospital at University of Utah Health, noted that barriers still exist. 

“Using inclusive language when talking to patients, taking into consideration each patient’s sexual orientation and gender identity, and using proper pronouns are very important, especially for transgender patients,” Marsco said. 

For hospitals that do not collect sexual orientation and gender identity (SOGI) data for their electronic health records or intake forms, Marsco said it’s OK for nurses to ask patients how they prefer to be addressed. SOGI information typically consists of a patient’s legal name, preferred name, preferred pronouns, legal sex, and sex assigned at birth. 

According to Marsco, this information is very helpful when caring for LGBTQ+ patients with cancer, especially transgender patients who may need cancer tests and treatments based on the sex they were assigned at birth rather than their current gender identity. 

“Specific cancers, such as breast cancer, have no gender,” Marsco said. “Breast cancer doesn’t just affect patients who were assigned female sex at birth, it also affects men and trans women.”

, found that trans women who received hormone therapy have an increased risk of breast cancer but may not receive information about prevention and screening.

 Last year, the American College of Radiology released transgender breast screening guidelines in an effort to improve screening in this setting.

To make breast cancer screenings more inclusive, Marsco said it’s important that cancer centers reconsider names such as “Women’s Cancer Care” in favor of names such as “Breast Cancer Center.” He adds that it’s also important for cancer centers to incorporate SOGI forms into their admissions process and strive to create a gender-diverse cancer center. This may include providing all-gender restrooms and visible signage that reflect sexual and gender minorities, as well as relevant education materials.

When a nurse introduces themself to a patient, Marsco encourages them to say something such as, “I’m your nurse, Lawrence, and my pronouns are he/him,” followed by asking the patient, “And you are?” If a nurse does not feel comfortable using pronouns without having gone through cultural competency training, he said they can simply ask how the patient prefers to be addressed. 

If a patient has a companion with them, Marsco encourages them to extend the same courtesy, rather than assuming the man accompanying the patient is his brother when it could be his husband. Rodriguez also cautioned nurses against making assumptions. As an example, he cited a study from the University of Washington School of Nursing which showed that lesbian individuals may be at higher risk of cervical cancer because they get fewer screenings than heterosexual women, due in part to health providers’ sometimes incorrect assumptions about their sexual history.

“The LGBTQ+ community comprises diverse groups of individuals with distinct health care needs,” Rodriguez said. “Making assumptions about patients can be dangerous and lead to lapses in care.”

Identifying Barriers to Care and Improving Research

In June, a qualitative study exploring investigators’ perspectives on the health needs of LGBTQ+ patients was published in the Journal of Gay & Lesbian Social Services.

 The study identified 4 areas as the most pressing health issues facing the LGBTQ+ community. They were:

• interconnectedness of physical, mental, and social health; 

• heteronormativity, or the belief that a heterosexual, cisgender identity is the only normal one; and 

• health care system barriers such as insurance plans that don’t cover necessary treatments and health care providers who haven’t been trained to handle LGBTQ+ concerns.

Don S. Dizon, MD, FACP, FASCO, a professor of medicine at Brown University, director of the pelvic malignancies program and hematology/oncology clinics at Lifespan Cancer Institute, and director of medical oncology and the oncology sexual health program at Rhode Island Hospital in Providence, noted that these types of barriers, combined with a lack of SOGI data, prevent oncology caregivers from fully understanding cancer risks, adverse effects, and outcomes LGBTQ+ patients face.

“Without collecting [these] data, it’s difficult to analyze outcomes and close the knowledge gap relating to LGBTQ+ patients and their cancer care and treatment,” Dizon told 

. “We need to ensure these patients have access to the screening programs they need and don’t delay care because they fear discrimination.” 

Dizon offered a hypothetical scenario of a transgender patient assigned female at birth who now identifies as male and has breast cancer. 

“Since some cancer protocols are sex/ gender specific, it can be difficult for an oncology team to know what to recommend for transgender patients,” Dizon said. “For a woman coming in on combined hormone therapy, who has been diagnosed with breast cancer, [it] would be recommended [that she stop] hormone therapy, but whether that’s the best course of action for transgender patients on gender-affirming therapy isn’t known.” 

Dizon said cancer screenings can be difficult for transgender patients who may no longer identify with the organs that correspond with the gender they were assigned at birth. In addition, cancer screenings aren’t tailored to trans and gender nonconforming patients.

“We know that sexual and minority gender populations are at risk for receiving disparate care and having suboptimal experience in their cancer care,” Dizon said. He hopes that as additional cancer centers begin SOGI data collection, the information will serve to include more representation of the LGBTQ+ community in clinical trials that results in tailored cancer prevention and treatment.

“Little research has focused on LGBTQ+ health disparities,” Dizon added. “We know that anal, breast, cervical, endometrial, colorectal, prostate, and lung cancer disproportionately affect the LGBTQ+ community, but we’re still working to fully understand how cancer affects LGBTQ+ patients and the best ways to reduce these disparities.”

Resources such as the National Institutes of Health’s Sexual & Gender Minority Research Office are working to advance research for LGBTQ+ patients. In addition, the PRIDE Study (pridestudy.org), which launched in 2015, invites members of the LGBTQ+ community to participate in the first largescale, long-term national health study of LGBTQ+ individuals designed to improve the health of the LGBTQ+ community and help health care providers deliver customized, inclusive care.

 This study is being conducted by Stanford University School of Medicine in partnership with the University of California, San Francisco.

“Researchers can gain essential insights into the health and well-being of LGBTQ patients through the PRIDE study,” Rodriguez said. “Additionally, there are other studies that are ongoing at academic research centers [such as] City of Hope to help further our knowledge on how to best treat LGBTQ+ patients with cancer.” 

1. Jones, JM. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17, 2022. Accessed November 3, 2022. https:// bit.ly/3UBswb2 

2. Sherman ADF, Cimino AN, Clark KD, Smith K, Klepper M, Bower KM. LGBTQ+ health education for nurses: an innovative approach to improving nursing curricula. 

. 2021;97:104698. doi:10.1016/j.nedt.2020.104698 

3. de Blok CJM, Wiepjes CM, Nota NM, et al. Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands.

 2019;365:l1652. Published 2019 May 14. doi:10.1136/bmj.l1652 

4. Transgender breast cancer screening, American College of Radiology. 2021. Accessed November 3, 2022. https://bit.ly/3fQwBsW 

5. Waterman L, Voss J. HPV, cervical cancer risks, and barriers to care for lesbian women. 

 2015;16;40(1):46-53. doi:10.1097/01.NPR.0000457431.20036.5c 

6. Ramsey Z, Davidov DM, Abildso CG. An etic view of LGBTQ healthcare: barriers to access according to healthcare providers and researchers. 

 2022;34(4):502-520. doi:10.1080/10538720.2022.2042452 

7. Your story. Your health. The PRIDE Study. Accessed November 7, 2022. https://bit.ly/3Th6bP1

Articles

Improve care for LGBTQ+ patients with cancer by learning about disparities, focusing on patient-centered treatment, and not making assumptions about patients and their loved ones. 

Cancer Has No Gender: Challenging Assumptions and Improving Quality of Care for the LGBTQ+ Community

When faced with a cancer diagnosis, patients may consider acupuncture, meditation, music therapy, and other supplemental care alternatives. However, they should make sure to go to professionals who understand oncology, nursing experts say. 

In July 2022, the University of Michigan released its National Poll on Healthy Aging, whose results showed that 2 in 3 adults between 50 and 80 (66%) reported using at least 1 integrative medicine strategy to treat a health problem. The most commonly used strategies were massage (41%), chiropractic (41%), meditation and mindfulness (27%), yoga (24%), and acupuncture (16%).

“We’ve definitely seen an increase in patients who are looking for more natural treatments to reduce side effects such as anxiety, fatigue, and nausea,” Carey Ramirez, ANP-C, ACHPN, an advanced practice manager in the Department of Supportive Care Medicine at City of Hope, told 

®. “Some patients are also reluctant to take opioids for pain and prefer a nonpharmacological option.”

Acupuncture is a popular choice for chronic cancer-related pain. The technique involves inserting thin, sterile needles into the body and can be administered only by licensed practitioners. Although not widely available, multiple studies have found it to be more effective than the control at reducing chronic pain.

Mao et al, for instance, found that 10 weeks of acupuncture greatly outperformed usual care at reducing chronic muscuoloskeletal pain. The therapy has also been shown to reduce nausea, fatigue, dry mouth, insomnia, and neuropathy in cancer patients.

Other integrative therapies, however, remain controversial because there is not enough evidence to support them and because they may have a negative effect on concurrent treatments. “We only recommend evidence-based complementary medicine treatments,” Ramirez said. “If a patient asks about…herbs and supplements, we’ll discuss the risks and benefits with them.” Ginger and garlic, he pointed out, may interfere with such anticoagulants as warfarin and increase a patient’s risk of bleeding.

City of Hope’s Department of Supportive Care Medicine gives cancer patients physical, psychological, social, and practical support that improves outcomes and enables them to maximize their personal strengths.The evidence-based complementary therapies it offers are art and music therapy, yoga, meditation, and animal-assisted therapy, whereby trained animals visit patients in the hospital. The Department also plans to add an acupuncturist to the staff this year.

According to Ramirez, “it’s important for patients to seek treatment from an acupuncturist…that specializes in oncology or a massage therapist trained in oncology massage” because practitioners “should be familiar with…[the] precautions that need to be taken…with cancer patients.”

Adding Integrative Care to Oncology Treatments

Farah Momin, BSN, RN, an assistant nurse manager at the Integrative Medicine Center of MD Anderson Cancer Center, said in an interview that patients may benefit from a referral to an center like hers. MD Anderson patients are referred for acupuncture, oncology massage, yoga, and meditation, all of which are offered by the Integrative Medicine Center. Its staff works closely with every patient’s oncologist to ensure treatments meet needs and supplement the traditional care patients are receiving.

“Our program uses a combination of integrative approaches to treat and heal the whole person,” Momin said. Patients come to her with questions about what foods to avoid while undergoing cancer treatment, what foods fight the disease, and how they can minimize common side effects like fatigue, pain, and nausea. “We have a dietician on staff who…tailor[s]…meal plan[s] that help them meet their dietary goals,” she explained, adding that they “also have an acupuncturist and [a] massage therapist trained in oncology…[who] can treat common side effects, including radiation-induced neuropathy and dry mouth caused by radiation or chemotherapy.”

In addition, and particularly after the start of the pandemic, patients often ask to meet with a psychologist to deal with the many emotions they experience after a cancer diagnosis. “Since we work with immunocompromised patients, many of our free group classes have moved online to ensure patient safety,” Momin said. “Yoga, Connect and Reflect with Music, and Cooking for Optimal Health are all offered virtually to…patients and…caregivers.” Studies have shown that music not only alleviates anxiety, depression, and pain in patients with cancer but also improves their quality of life.

Momin has seen complementary medicine help patients with many side effects of cancer and empower them as well—as long as pracitioners understand their needs. “Choosing to participate in an integrative medicine practice…can give cancer patients a sense of control” because “they’re being proactive and addressing the psychological and emotional aspects of their condition.”

A valuable resource for oncology nurses and other health care providers, the 

 will be holding its annual conference October 20-22 at The Scott Resort & Spa, in Scottsdale, Arizona.

1. Use of and Interest in integrative medicine strategies, July/August 2022. University of Michigan National Poll on Healthy Aging. Accessed September 7, 2022. https://bit.ly/3SmQndt

2. Mao JJ, Liou KT, Baser RE, et al. Effectiveness of electroacupuncture or auricular acupuncture vs usual care for chronic musculoskeletal pain among cancer survivors: the PEACE randomized clinical trial. 

 2021;7(5):720-727. doi:10.1001/jamaoncol.2021.0310

3. Lu W, Dean-Clower E, Doherty-Gilman A, Rosenthal DS. The value of acupuncture in cancer care. 

. 2008;22(4):631-648, viii. doi:10.1016/j.hoc.2008.04.005

4. Wang Y, Tang H, Guo Q, et al. Effects of intravenous patient-controlled sufentanil analgesia and music therapy on pain and hemodynamics after surgery for lung cancer: a randomized parallel study. 

. 2015;21(11):667-672. doi:10.1089/acm.2014.0310

5. Abebe W. Review of herbal medications with the potential to cause bleeding: dental implications, and risk prediction and prevention avenues. 

. 2019;10(1):51-64. doi:10.1007/s13167-018-0158-2

Holistic options like acupuncture and music therapy may benefit those undergoing cancer treatment. 

Helping Patients Navigate Complementary Treatments

Because of the risks associated with handling chemotherapy drugs, safety guidelines surrounding their proper use have existed since 1981.

 The Oncology Nursing Society (ONS) and the National Institute for Occupational Safety & Health (NIOSH) have both recommended oncology nurses receive hazardous drug education, including safe storage, preparation, labeling, transportation, administration, and disposal of hazardous drugs and proper use of personal protective equipment (PPE).

In 2016, the United States Pharmacopeial Convention (USP) updated the General Chapter 

<800> to set standards for the safe handling of hazardous drugs, with implementation of the new standards set scheduled for December 2019. Almost 3 years after 

 <800> became the recommended standard, some hospitals have improved their compliance, but Seth Eisenberg, ASN, RN, OCN, BMTCN, a retired oncology nurse now working as a consultant in Saint George, Utah, believes implementing 

 <800> is still a work in progress for many hospitals.

<800> requires pharmacies to store hazardous drugs in an externally ventilated, negative-pressure room with at least 12 air changes per hour,” Eisenberg said in an interview with 

®. “For pharmacies that were housed in the basement of a hospital, this entail[ed] expensive modifications. In some cases, it was more cost-effective to build a new pharmacy rather than retrofit an old one.”

 <800> compliance entails increasing education about proper handling of hazardous drugs, implementing closed system drug-transfer devices (CSTDs), and using requisite PPE, according to Eisenberg. “One of the biggest changes in 

 <800> is the requirement to use CSTDs when administering drugs,” he said. “Although ONS and NIOSH had recommended these devices, they weren’t required.”

CSTDs can prevent or minimize drug leakage, but Eisenberg said the cost can be prohibitive for some hospitals and clinics. “[Because] some components of CSTDs are meant for single use, it increases the overall cost of the medication,” he said. “The average price of a CSTD ranges from $8-$12 a dose.”

 <800> requires nurses to double-glove and wear chemotherapy gowns, when administering chemotherapy drugs, which is consistent with ONS guidelines.

“NIOSH has provided best practice guidance for more than 2 decades. But 

 <800> is an enforceable standard with far-reaching implications for all facilities that handle hazardous drugs,” Eisenberg says.

Although guidelines for safe handling of hazardous oncology drugs aren’t new, 

 <800> introduced safety standards that could be enforceable on a state level.

 <800> gave teeth and enforceability to safety practices that already existed,” AnnMarie Walton, PhD, MPH, RN, OCN, CHES, FAAN, assistant professor in the School of Nursing at Duke University in Durham, North Carolina, explained in an interview with 

 <800> is still a work in progress for many oncology units. Some of the oncology units that weren’t already using CSTDs are adopting them now that suppliers are able to meet the demand. Enforceability of the 

 <800> requirement is being decided and regulated at the state level.”

Walton said oncology nurses are in a good position to advocate for safety changes and encourage adoption of 

 <800> if their unit hasn’t already implemented them. In addition, oncology nurses can educate patients and their caregivers on safety measures that should be followed while chemotherapy is administered in the hospital or at home after the patient is discharged.

MiKaela M. Olsen, DNP, MS, APRN-CNS, AOCNS, FAAN, clinical program director for oncology at The Johns Hopkins Hospital in Baltimore, Maryland, works at a hospital that began offering a curbside injection clinic to oncology patients in 2020, during the height of the pandemic. 

“We had to find a way to ensure our patients could safely continue receiving chemotherapy while also protecting them from the coronavirus,” Olsen told 

Johns Hopkins initially conceived curbside injection clinics as a precaution during the pandemic. But Olsen said Johns Hopkins plans to continue these clinics for patients receiving chemotherapy, and other hospitals have taken notice. “For many oncology patients, the curbside injection clinic offers both increased safety and convenience,” Olsen said. “They still have the option of our indoor injection clinic, but for patients with transportation and mobility issues, the curbside clinic is easier. They can have a family member drive them or take an Uber or Lyft to their appointment.”

Nurses staffing the curbside injection clinic wear full PPE, follow safety protocols, and offer services including symptom assessment, port flushes, dressing changes, and chemotherapy. To date, the curbside injection clinic has seen over 7000 patients. Although large health systems such as Johns Hopkins have embraced 

<800>, Olsen acknowledged that some smaller community hospitals are still working to implement 

 <800> safety requirements. One way for hospitals to do this is to request a Health Hazard Evaluation from NIOSH. This evaluation identifies potential health hazards and recommends ways to reduce exposure. There is no cost for the evaluations, but they pay off by providing peace of mind.  “Compliance challenges vary from one health care setting to the next, but nurses can help identify areas in need of improvement,” Olsen said. 

Bernabeu-Martínez MA, Ramos Merino M, Santos Gago JM, Álvarez Sabucedo LM, Wanden-Berghe C, Sanz-Valero J. Guidelines for safe handling of hazardous drugs: a systematic review. 

. 2018;13(5):e0197172. doi:10.1371/journal.pone.0197172

USP<800> Compliance: A Hazardous Drug Safe-Handling Quality Improvement Project for Ambulatory Care Infusion Nurses

. Doctor of Nursing Practice thesis. University of San Francisco; 2020.https://repository.usfca.edu/dnp/218

Powerful chemicals used in chemotherapy may pose safety hazards for oncology nurses, pharmacists, and other health care providers if not handled properly.

USP <800>: Still a Work in Progress?

Clinical trials have long faced a multitude of challenges, including patient enrollment and retention. Now decentralized clinical trials (DCTs) that allow patients to participate remotely intend to simplify the process.

DCTs are defined as studies “executed through telemedicine and mobile/local health care providers, using processes and technologies differing from the traditional clinical trial model.”

 These trials go beyond traditional brick-and-mortar research facilities to allow many clinical trial activities to be conducted virtually rather than in person.

By utilizing technology, such as telemedicine, to deliver consent and education, remote monitoring, direct-to-patient distribution of investigational medicines, and use of local labs and image centers, DCTs offer a more patient-centric approach to clinical trials.

Although there has long been an interest in decentralizing clinical trials, the COVID-19 pandemic significantly sped up the adoption of DCT methods. Suddenly, patients were unable to physically visit clinical trial sites, and the Lancet reports an estimated 80% of non–COVID-19 trials were either halted or interrupted by the pandemic.

Although DCTs are proving to be promising, Abraham says they present some challenges. “During the pandemic, exceptions were made to allow for virtual assessments in our breast oncology research group, and we have the ability to allow more virtual assessment for patients with all cancer types,” she said. “However, insurance requirements have recently become stricter and don’t always allow coverage for out-of-state virtual assessments. Unfortunately, this may hinder the progress of decentralizing clinical trials in the future.

“We’ve worked to decentralize many of our trials to help fit the needs of our patients during the pandemic,” Elizabeth Abraham, RN, BSN, a senior clinical research nurse in breast oncology at Massachusetts General Hospital in Boston, said in an interview with Oncology Nursing News®. “Our team modified the process to allow for virtual prescreening for trials, virtual consents, telephone adverse event assessments, and virtual visits.”

Another challenge is ensuring study participants receive immediate care in the event they become ill. “If a patient is experiencing any adverse events, they must come into [the] clinic or be seen locally for [an] in-person evaluation,” Abraham said. “If they are seen locally, our clinical research team will obtain records for review to provide recommendations and guidance.”

Although DCTs are proving to be promising, Abraham says they present some challenges. “During the pandemic, exceptions were made to allow for virtual assess- ments in our breast oncology research group, and we have the ability to allow

A Southern California Cancer Center Expands Its Reach 

With over 35 locations in Southern California, City of Hope, a cancer research and treatment organization, employs a hybrid approach to decentralizing its clinical trials. Instead of relying on its main campus in Duarte as the primary clinical trial site, it uses its satellite locations in Lancaster, South Pasadena, Upland, and Corona, to recruit patients and stream data. 

Paul Raborar, RN, a clinical research nurse at City of Hope, oversees clinical trials at these satellite sites and believes offering DCTs in the communities where many of their patients live will enable faster and more diverse enrollment in their clinical trials. 

As an example, Raborar cited a recent clinical trial for prostate cancer (NCT04734730), a type of cancer that disproportionately affects Black men, who are more likely to receive a diagnosis at an advanced stage. “The community sites have provided 31% of the study population to date,” he said. “There has been an uptick in enrollment. Opening up in the community created new patient inflow. Some studies incurred their first patients from the DCT.” 

Through City of Hope’s Division of Health Equities, the staff provides prostate cancer education and free screenings to Black and Latino men in the greater Los Angeles area. In addition to conducting outreach, they also discuss City of Hope’s current clinical trials. “We cast a wide net, and through our community outreach events, we [are able to] build trust with patients,” Raborar said. “We also educate our community practice site doctors on our clinical trials so they can refer a wide range of patients to our trials.” 

Although DCTs are gaining in popularity, Raborar says they are not without their own challenges. “The 3 biggest challenges are securing the right infrastructure and technology, ensuring sufficient study target population and diversity at sites, and coordinating financial and insurance concerns in conjunction with study requirements,” Raborar said. “Managing all 3 challenges is essential for patient safety, the protection of study participants’ rights, proper performance of study requirements, and minimizing its financial burden.” 

For oncology nurses, Raborar noted that DCTs represent an interesting job opportunity for those who want to pursue a career in research. “Depending on each site’s requirements, a clinical research nurse should have good assessment skills, exceptional communication and teaching [abilities], and 2 years’ experience in oncology or research nursing, but they do not need to have a background in both oncology and research,” he said. 

To work in DCTs, Abraham said nurses should also have experience working with diverse patient populations while maintaining cultural competency. 

“This requires nurses to work well with non-English speaking patients by using interpreter services by phone,” she said. 

In return, Abraham believes DCTs present oncology nurses with the opportunity to move beyond the bedside and work on research that has the potential to make a significant impact on patient care. In addition to giving nurses the opportunity to improve the telehealth experience for patients and health care workers alike, it allows the nurses themselves more variety in their work. 

“Decentralizing clinical trials allows nurses to have more diverse opportunities,” she said. 

Supporting decentralized trial approaches. Clinical Trials Transformation Initiative. Accessed March 15, 2022. https://bit.ly/3CN7DBL

van Dorn A. COVID-19 and readjusting clinical trials.

.2020;396(10250):523-524. doi:10.1016/S0140-6736(20)31787-6

Evolving technology and adaptability allow for a more patient-centric approach to clinical trials; however, there are some limitations.

Decentralized Clinical Trials: Bringing Care Directly to Patients

When the COVID-19 pandemic began, oncology units faced a daunting challenge. They had to adapt to providing cancer treatments without sacrificing the health and safety of immunocompromised patients, their families, and oncology staff. Today, as COVID-19 persists and new variants emerge, oncology units have implemented a variety of safety measures that allow them to coexist with the coronavirus, while ensuring the continuum of cancer care.

“Post pandemic, medical care will never be the same,” said Anna L. Rodriguez, MSN, MHA, RN, OCN, NEA-BC, chief nursing officer and vice president of nursing and patient care services at Fox Chase Cancer Center in Philadelphia, Pennsylvania. "The coronavirus pandemic has highlighted the ability of hospitals to quickly adapt their care models in response to external factors, to ensure a safe environment for staff and patients,” she said.

Rodriguez expects many of the rigorous safeguards implemented to protect patients and staff to remain in place long after the pandemic ends. As one example, she points to the use of technology platforms for virtual staff meetings and patient visits. “Having this flexibility has allowed health care organizations to maintain business operations while allowing for required social distancing as the current conditions dictate, to protect our patients and workforce,” she said. “I believe the efficiencies, work-life balance, and accessibility offered by these platforms will ensure their continued use.”

At City of Hope, a leading cancer research and treatment hospital near Los Angeles, California, use of the hospital’s telehealth platform skyrocketed during the pandemic. The Hope Virtual platform offered a way for doctors and nurses to safely communicate with patients.

Susan J. Brown, PhD, RN, senior vice president of patient care services and chief nursing officer at City of Hope, believes that telehealth has replaced many routine oncology appointments by allowing oncology team members to communicate with patients over a secure video platform via smartphone, tablet, or computer.

“Telehealth is used when patients, or someone they are in close contact with, are symptomatic with COVID-19 or the flu, when they have transportation issues, or when they would like a family member to join the appointment from another location,” Brown said. “Prior to the pandemic, we conducted approximately 10% of visits using telehealth. Today, approximately 35% to 40% of patient visits are conducted using telehealth.”

Brown said nurses can safely evaluate patients with cancer using telehealth; they can also manage the adverse effects of treatment, review laboratory and scan results, answer questions, and include family members in the patient’s care. City of Hope plans to expand their telehealth program to include remote chemotherapy support, telegenetics, and much more.

In February 2020, UC Davis Medical Center in Sacramento, California, reported the first case of community transmission of COVID-19 in the United States. This led to important changes in the Centers for Disease Control and Prevention (CDC) guidelines for novel coronavirus testing.

Devon Trower, BSN, RN, OCN, a nurse manager in adult infusion at UC Davis Comprehensive Cancer Center, said the entire medical center quickly implemented safety procedures. These included limiting the number of visitors, screening patients and employees for infection daily, maintaining social distancing, mandating masks, and providing ample sanitizer and handwashing facilities.

If an oncology patient tests positive for COVID-19 but is asymptomatic, their doctor will balance the risk of postponing their treatment with their diagnosis. If the patient is exhibiting symptoms, the doctor will determine whether they have recovered enough to undergo treatment.

“We now have several isolation rooms that use negative air pressure where we can administer medications intravenously to oncology patients who have tested positive for COVID-19,” Trower said.

Since the beginning of the pandemic, the oncology unit has been working closely with the hospital’s infection control staff to safeguard the health of patients and oncology team members. “The pandemic has given us all a heightened awareness of infection prevention,” Trower noted. “While we always wore PPE [personal protective equipment] when administering chemo[therapy], our staff now wears N95 or surgical masks all the time.”

Findings from a survey released in March 2021 by the American Society for Radiation Oncology showed that enhanced safety protocols remained widespread at radiation therapy clinics. Masking for patients and staff (99%), social distancing in the clinic (100%), and screening patients and staff for COVID-19 exposure (95%) were nearly universal. Increased sterilization (93%), face shields for staff during procedures (80%), and no-visitor policies (73%) were also common.

At the beginning of the pandemic,according to Brown, City of Hope quickly began implementing new screening protocols and safety measures recommended by the CDC, as well as guidelines offered by the Oncology Nursing Society. As PPE was only available in limited quantities, City of Hope changed their policy to preserve supplies.

“Staff used to don a mask when entering a hematology patient’s room and throw it away when exiting; it wasn’t unusual to go through 50 to 60 masks in 1 day,” Brown said. “We changed our policy to 1 mask per employee per day and haven’t experienced any increases in infection.”

In fact, in the midst of the pandemic, City of Hope was awarded the prestigious Magnet recognition from the American Nurses Credentialing Center, a distinction bestowed on only 9% of hospitals in the United States. Brown says the pandemic also underscored the importance of supporting and celebrating nursing staff, while ensuring their safety.

“When we presented our nurses with DAISY awards over the past 2 years, we practiced social distancing by decorating golf carts and parading the award winners around our campus,” she explained. “It’s been so well received that we plan to continue the tradition post COVID-19.”

Brown noted that one safety protocol that will probably be altered is the hospital’s visitor policy.

“Inpatients can only have 1 visitor at a time and each visitor must provide proof of full COVID-19 vaccination or a negative [result from a] COVID-19 test taken within the prior 72 hours of each visit,” she said. “Visitors must also be masked at all times.”

Although the practice safeguards the health of patients and staff, Brown noted
the policy has been hard for both nurses and patients.

“Patients miss having their families present and our nurses have realized how much families not only help with patient morale, but also assisting with simple things such as bringing their loved one a glass of water,” Brown said. “Patients have been largely communicating with their extended family via iPads or smartphones.”

Visitor policies have also changed in the outpatient setting. Brown says trained City of Hope escorts meet patients in the lobby and accompany them to infusion and radiation treatments.

“At our main campus, 1 visitor may accompany adult patients and 2 visitors for those under 18 when they meet a physician for the first time and for presurgery anesthesia testing, before and after surgery, and urgent care visits,” she said.


 To ensure patients test negative for the disease prior to undergoing surgery, City of Hope also implemented drive-through COVID-19 testing to screen patients.

“If they test positive, the surgery might still be conducted if deemed urgent,” Brown says. “If not, the surgery will be postponed.”

Rebecca Farrell, MSN, RN, clinical nurse manager of ambulatory care at Fox Chase Cancer Center, added that interventions to screen and prescreen patients for COVID-19 symptoms prior to their treatments may also become the new normal. These screening tests evaluate for symptoms such as a new or worsening cough within the past 14 days, shortness of breath, fever, and possible COVID-19 exposure.

“Prescreenings and pretesting might become part of our oncology playbook,” she said. “We’ve also seen how team-based nursing care models can be effectively used to care for critical patients during the COVID-19 surge, with nursing staff cross-training in various specialties and departments.”

Some nurses see safety measures such as increased masking and hand-washing stations throughout the hospital remaining.

“While we’ve always been concerned about infection prevention, we’ve seen how these enhanced safety measures taken to prevent the spread of COVID-19 have also squashed the transmission of seasonal influenza and respiratory viruses and maximized safety for our patients,” said Trower.

Results of a national physician survey by the American Society for Radiation Oncology (ASTRO). ASTRO. Accessed January 10, 2022. https://bit.ly/332MTZm

The COVID-19 pandemic has affected oncology practice in many ways. What will safe treating look like moving forward?

Shifts in Oncology: Safely Treating Patients in a Post–COVID-19 World

Although surgery is an option for some patients with lung cancer, unmet needs related to postoperative recovery can negatively affect a patient’s quality of life and increase the family caregiver’s burden, explained Virginia Sun, PhD, MSN, RN, associate professor in the Division of Nursing Research and Education at City of Hope, a cancer research and treatment organization near Los Angeles, California.

To address these needs, Sun and her colleague, Jae Kim, MD, assistant professor and chief of the Division of Thoracic Surgery at City of Hope, launched a 5-year study in 2018 focusing on how to best support family care-givers after a loved one has undergone surgery for lung cancer. Sun and Kim developed the study after working on a previous research project that showed although standard intervention and education methods, such as videos and printed materials, were helpful for patients, they weren’t as helpful for caregivers.

Sun’s study examines the differences between a caregiver control arm that receives traditional education materials and one that receives these materials as well as face-to-face sessions with an oncology nurse to help address specific patient and caregiver needs and problems.

Although some oncology centers have nurse navigators that work with family caregivers, that isn’t the case with all medical centers. Sun said it’s important for all oncology nurses to ensure good outcomes for patients with lung cancer by ensuring their caregivers are well prepared.

With an increase in minimally invasive surgery for lung cancer, the length of hospital stays has decreased, with patients now typically spending 2 to 3 days in the hospital after minimally invasive surgery. Although many patients prefer to recover at home, Sun said when caregivers aren’t adequately prepared, patients with lung cancer can experience complications that result in being readmitted to the hospital.

Caregiver preparation often consists of videos and print materials developed by groups, such as the American Society of Clinical Oncology. Although those resources are informative, caregivers often need more personalized support, Sun said.

“Oncology nurses can help families and family caregivers by simply asking them about their needs and how they are doing,” she said. “Many family caregivers report they’ve never been asked about their needs. A simple question can lead to improved assessment, provision of relevant information, and referrals for support to families.” Sun recommended that oncology nurses determine who will be the primary family caregivers for a patient, and whether there will be more than 1 family member taking on this role, and assess their knowledge needs and caregiving preparedness. “Most family members are interested in how they can better prepare for the day of surgery and the recovery process, and what to expect during these times,” Sun said. “If possible, nurses can think about how we can best use the preoperative period to educate and prepare families for what’s ahead and to also encourage care- givers to think about their own self-care plan, as many family caregivers may be coping with their own illness.”

Shayne Cardozo, RN, nurse coordinator for the thoracic surgery and oncology clinic at the University of California, San Francisco Health, works with many patients with lung cancer and their family caregivers and strives to give them the information and support they need after they’re discharged from the hospital. “The quality of life for these patients with lung cancer should be the same or better after surgery,” Cardozo said. “We stress an active recovery where, after receiving approval from their doctor, they engage in walking and deep breathing exercises. The more they can do, the faster they will recover.”

In addition, Cardozo demonstrates how to properly use devices, such as an incentive spirometer, so patients can expand their lungs to help them breathe more deeply and fully. Doing this, as well as regular breathing and coughing exercises, also helps patients to keep their lungs active during their recovery and prevents complications, such as pneumonia.

Cardozo also works with patients to develop a personal plan to treat postsurgery pain and address common adverse events, such as constipation caused by pain medications. “At-home patients tend to fall behind on their pain medications,” she said. “Many are fearful they will become addicted to pain medications, so it’s important to let them know prescription opioids are generally safe when prescribed by their doctor and taken for a short period of time.”

Cardozo sees the role of a family caregiver as that of a personal trainer who offers encouragement and support to their loved ones by ensuring they follow postoperative instructions, take their medications, and practice breathing exercises. She also advises care- givers to call her in the event they have questions or if their family member experiences a fever, discharge from the incision site, chest pain, or shortness of breath.

Sometimes the most important tool that oncology nurses can provide caregivers is reassurance. “Caregivers need to feel empowered that they are part of the health care team and have the tools and answers in place to care for their loved one,” Cardozo said. 

Prieto R, Ferrell B, Kim JY, Sun V. Self-management coaching: promoting postoperative recovery and caregiving preparedness for patients with lung cancer and their family caregivers. 

. 2021;25(3):290-296. doi:10.1188/21.CJON.290-296

As minimally invasive surgery for lung cancer increases in popularity, more patients are recovering at home, expanding the need for personalized caregiver education.

The Oncology Nurse’s Role in Preparing Patients and Caregivers for Postoperative Recovery

Three years ago, LaToya Lewis, EdD-CI, MSN, RN, and her colleagues embarked on a study to evaluate horizontal violence and bullying among nurses who work in oncology inpatient units and outpatient services at an academic medical center in South Florida.

Although bullying and incivility in nursing are not new issues, they are a pervasive problem. A 2017 survey found that 45% of nurses had been verbally harassed or bullied by other nurses, and 41% had been bullied by managers or administrators. And although previous studies have examined how bullying affects all nurse specialties, Lewis, an assistant professor of clinical at the University of Miami School of Nursing and Health Studies in Florida, and her colleagues specifically looked at how bullying affected oncology nurses.

“Through our survey, we found that bullying was more prevalent in the outpatient oncology clinic, although nurses who worked in both inpatient and outpatient settings experienced conflict,” Lewis said.

Many of the nurses surveyed experienced horizontal or lateral violence, which Lewis described as nonphysical, hostile, aggressive, or harmful behavior toward a coworker.

“Horizontal violence is characterized by emotional, verbal, and defiant behaviors such as snide remarks, public humiliation, talking down to a colleague, mocking, harassment, and intimidation,” Lewis said. “Physical violence can involve pushing, grabbing, or invading a coworker’s physical space.”

All forms of workplace bullying can take their toll on nurses and lead to reduced self-esteem, anxiety, depression, and even physical symptoms such as insomnia and gastrointestinal issues.

“Many nurses reported feeling hesitant to report the bullying because they thought it would only make the situation worse,” Lewis explained. “The effects of horizontal violence and bullying not only negatively impact a nurse’s professional quality of life, they also affect nursing retention and employee and patient satisfaction.”

When the survey was completed, Lewis and her colleagues reported the findings to hospital administrators, who were surprised by the results.

“The administration believed they had a zero tolerance for workplace bullying, and they weren’t aware of some of the incidents,” Lewis said. “Many nurses suffered in silence rather than voice their concerns because they had seen others report horizontal violence, only to have the problems persist.”

As a result, the medical center began incorporating education about appropriate professional behaviors that are consistent with the hospital’s code of conduct into orientations for new hires, Lewis said. Administrators also worked to engage midlevel nurses and other oncology staff to advocate for a culture of kindness and civility.

“In addition to establishing programs that promote awareness and discuss how to address workplace bullying, the medical center also put a renewed emphasis on positive behavior and the contributions of their nursing staff through programs such as the DAISY Foundation awards,” Lewis said. “Nursing leaders can create a positive work environment that serves to thwart workplace bullying.”

Judith Vessey, PhD, MBA, FAAN, the Lelia Holden Carroll Professor in Nursing at Boston College’s Connell School of Nursing in Massachusetts, also has conducted research on horizontal violence and bullying among nurses.

In her study “Bullying of Staff Registered Nurses in the Workplace,”

 which was published in 2009, Vessey and her colleagues found that perpetrators of workplace bullying included senior nurses, charge nurses,
nurse managers, and physicians who publicly humiliated, isolated, excluded, or excessively criticized staff nurses. According to Vessey, stress levels were reported as moderate to severe among nurses. The lack of an
available workplace solution meant that support was found primarily among family, colleagues, and friends.

“It’s important to begin by looking at what’s happening at the unit level, how good is the leadership, and [whether] nurses see themselves as part of a team and have a sense of psychological safety,” Vessey said. “Unfortunately, some nurses work in an unhealthy environment where they don’t feel safe speaking up.”

Vessey explained that psychological safety is when an employee can speak up without risking embarrassment, humiliation, or punishment.

All nurses should feel safe in their workplace and have the tools and support needed to combat bullying, violence, incivility, and toxic environments.

Linda Childers

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