Skin cancer continues to be the most common type of cancer in the United States (US), and it is predicted that the number of people diagnosed with skin cancer will grow. The US Preventive Services Task Force (USPSTF) reviewed studies on counseling patients about sun protection to identify outcomes, behavior changes, and skin cancer incidence.

The task force found that behavioral counseling interventions are of moderate benefit in increasing sun protection behaviors in children, adolescents, and young adults with fair skin types. Because most trials of skin cancer counseling predominantly included people with fair skin types, the USPSTF limited its recommendations to this population.

 counseling fair-skinned young adults, adolescents, children, and parents of fair-skinned young children about minimizing exposure to UV radiation to reduce their risk of skin cancer. Clinicians should selectively offer counseling to fair-skinned adults age 24 and older since the net benefit of counseling this group is small.

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Behavioral counseling interventions are of moderate benefit in increasing sun protection behaviors in children, adolescents, and young adults with fair skin types.

Updated Skin Cancer Prevention Guidelines

The Food and Drug Administration (FDA) estimates that the market for homeopathic drugs is about $3 billion. In an effort to crack down on the industry, the FDA announced a new, risk-based approach to regulating homeopathic treatments.

Homeopathy is defined by the FDA as the practice of treating disease with remedies that have produced similar syndromes and conditions in healthy subjects. The FDA further defines a homeopathic drug as any drug listed in the Homeopathic Pharmacopeia of the United States, an addendum to it, or its supplements. The potencies of homeopathic drugs are specified in terms of dilution (e.g. 1/10) and must contain diluents commonly used in homeopathic pharmaceutics. Drug products containing homeopathic ingredients in combination with non-homeopathic active ingredients are not considered homeopathic drugs by the FDA.

Homeopathic drugs are often marketed to treat a wide variety of diseases and disorders, including cancer, dementia, and attention-deficit hyperactivity disorder. However, there is no evidence that they are effective.

, the FDA will regulate certain categories of homeopathic drugs it considers to be risky, such as drugs whose ingredients are potentially toxic or harmful, drugs that are not taken orally or topically, and drugs marketed to people with life-threatening conditions and "vulnerable populations" like children and the elderly.

FDA Cracks Down on Homeopathic Drugs to Protect Consumers

Women presenting with breast pain are often sent by their clinicians for different types of breast cancer testing — typically undergoing mammography, an ultrasound, and a physical exam &mdash; despite there being a lack of association between the pain and cancer.

Researchers from Arizona and California decided to examine the benefit of this testing and if the workup is cost effective.

They reviewed medical records of 7202 consecutive patients, who were seen at least 1 time, at the Breast Clinic at Maricopa Medical Center in Phoenix from June 1, 2006 to February 28, 2017.

About 15% of patients (1017 of 7202) presented with a complaint of breast pain, according to the 

 that was presented at the 2017 San Antonio Breast Cancer Symposium. Some patients (702) were referred to the breast clinic for a breast “mass,” but were found to have only breast pain. Of the 1719 patients with breast pain, 15 (<1%) were found to have breast cancer. None of the patients found to have cancer were at increased risk per Gail Model risk estimates.

Most patients underwent evaluation of their breast pain: 85% breast imaging (mammogram, ultrasound, MRI, or CT scans), 32% biopsy, and 68% blood tests.

Although breast pain is a common complaint, workup beyond physical examination does not appear to be cost effective for patients under age 40 for whom it is not recommended to undergo screening, concluded the researchers. In patients age 40 and older, mammography should be performed if the patient has not been participating in routine screening. Diagnostic imaging in the absence of findings on screening and laboratory tests do not appear beneficial in patients with breast pain.

Though women presenting with breast pain are often sent by their clinicians for different types of breast cancer testing &mdash; typically undergoing mammography, an ultrasound, and a physical exam &mdash; a new study reveals that breast pain is not necessarily an indicator of cancer. 

Breast Pain Does Not Necessarily Indicate Breast Cancer

Cancer survivors may experience post-treatment effects, including frailty, cardiac dysfunction, osteoporosis, pulmonary fibrosis, hormone disruption, and secondary cancers. It’s unknown how or why these effects occur at the cellular level.

To learn more about the cellular biology of aging and the effects of cancer treatment on aging, researchers from Mayo Clinic, St. Jude Children’s Research Hospital, and City of Hope Medical Center conducted a comprehensive 

The researchers noted that cancer treatment is associated with accelerated aging. They theorize that multiple pathways contribute to it, as well as the development of late complications among cancer survivors.

Several chemotherapeutic agents are associated with the pathogenesis of senescence and acquired telomeropathies, which culminate in morbidity and mortality due to frailty phenotypes and aging-associated diseases. Additionally, the researchers wrote that few studies evaluate aging parameters (telomeres, p16

 senescent cells, miRNA, methylomes) in the context of clinical outcomes.

They recommend additional research to explore the mechanisms of accelerated aging-like phenotypes among cancer survivors with a goal of using this information to prevent or mitigate late complications of cancer treatment.

Researchers investigate the cellular biology of aging and the effects of cancer treatment associated with accelerated aging. 

Cancer Treatment Effects at the Cellular Level

People with non-alcoholic fatty liver disease (NAFLD) are at a greater risk of developing cancer that those who don't have it, according to a 

Researchers in Korea investigated Korean cancer incidence rates among people with NAFLD since there has been insufficient data on whether there is an association between the two. Ultrasonography was used to diagnose NAFLD in the absence of known liver disease, including alcohol-related and viral hepatitis.

Of 25,947 people studied, 8721 (33.6%) had NAFLD. During the follow-up that averaged 7.5 years, the cancer incidence rate of the NAFLD group was significantly higher than that of the non-NAFLD group. NAFLD was associated with the development of 3 cancers: hepatocellular carcinoma, colorectal cancer in men, and breast cancer in women. Although the study followed Korean patients, the large number of people studied suggests that NAFLD may be prevalent in other countries, too.

Since NAFLD is affected by the amount of fat in the liver, people who are overweight or obese, have diabetes, or high blood pressure often are at risk. The number of these people worldwide is growing; consequently, the incidence of NAFLD may rise. The American Liver Foundation cites a 25% incidence of NAFLD among Americans, so clinicians in the United States need to be aware of the association between NAFLD and cancer, and screen people at high risk.

Non-alcoholic fatty liver disease (NAFLD) is a risk factor for cancer, according to a recent report about a 7.5-year Korean study.

Link Between Non-Alcoholic Fatty Liver Disease and Certain Cancers

Sydney J. Harris, an American author and syndicated columnist for the 

, wrote that the words information and communication often are used interchangeably but signify different things. Harris, who died in 1986, astutely noted that “information is giving out and communication is getting through.”

Effective communication is an interactive process, with both parties mutually engaged in the conversation. However, all too often our interactions are anything but effective—and in oncology practice, poor communication with patients can lead to confusion or misunderstanding and potentially compromise patient care.

To identify best practices for effective communication with patients with cancer, the American Society of Clinical Oncology convened a multidisciplinary panel of experts in medical oncology, psychiatry, nursing, hospice and palliative medicine, communication skills, health disparities, and advocacy to review the literature and formulate recommendations. The panel addressed several areas, ranging from identifying core communication skills to describing strategies for related training.

One of the core recommendations is to determine the patient’s understanding of his or her disease, clinical status, and prognosis. Sounds simple enough, but many patients do not fully know or understand the extent of their disease. I still remember the patient who watched the oncologist draw the anatomy of the colon on exam room paper and write survival statistics next to it, yet when I asked that patient what he knew about his disease, he said, “I have a 60% cancer of the semicolon.” That type of response illustrates the importance of assessing the patient’s understanding.

Patients often get flustered when asked to repeat what they have been told or taught. A better way to assess their understanding is to say, “I want to be sure I’ve done a good job explaining this. Please recap what we’ve been talking about.”

When a misunderstanding is identified, the clinician can respond, “I haven’t done a very good job explaining this,” and then use a different approach to convey information.

Prior to each conversation, the clinician should review the patient’s medical information, establish goals for the conversation, and anticipate the needs and responses of the patient and family, according to the recommendations. Providing information is easy but skips the step of mutually establishing goals for the conversation. Teaching about treatment adverse effects, for instance, will be ineffective if the patient is focused on the unexpected news of a cancer recurrence.

Simply asking “What would you like to discuss or learn about during today’s visit?” can identify the patient’s needs and priorities and reduce time wasted discussing topics of little or no interest to the patient.

When patients who are asked what they’d like to talk about say that they have nothing specific to discuss, consider asking “What is of most concern to you right now?” The answers often are surprising and may be completely unrelated to the patient’s cancer treatment. This question also helps individualize documentation of the patient’s visit.

Another recommendation centers on patients’ awareness of all treatment options, including clinical trials and palliative care, which can be initiated simultaneously with other treatment modalities when appropriate. The panel used the term bidirectional in reference to discussions of end-of-life care and advised starting conversations about the patient’s preferences early in the course of incurable disease, readdressing the topic periodically, based on the patient’s clinical course.

“Enter clinical encounters with a sense of curiosity, aware that any patient and family, regardless of their background, may have beliefs, experiences, understandings, and expectations that are different from the clinician’s,” recommends the panel.

In practical terms, that means suspending judgment and making an effort to learn more about the patients. It also presents an opportunity to examine our biases and assumptions and learn more about ourselves, as well.

The experts recommend communication skills training for clinicians that includes learning about self-awareness and situational awareness related to emotions, attitudes, and underlying beliefs that may affect communication. One strategy to develop awareness involves reflecting on difficult, challenging, or unpleasant patient encounters, along with considering the elements of patient care that are satisfying or provide a sense of meaning.

The consensus guidelines, published on September 11, 2017, are available at ascopubs.org/doi/full/10.1200/JCO.2017.75.2311. To facilitate communication skills training, a number of no-cost resources have been developed, including slide sets, a data supplement, and clinical tools and resources (accessible at asco.org/supportive-care-guidelines). A 13-page summary of the guidelines also is available (consider posting 1 page a week in the workplace), along with patient resources, including videos on talking with a healthcare team, a list of questions to ask, tips to facilitate communication, and navigating challenges, such as making decisions, managing costs, and finding emotional support.

To help convey effective messages, nurses should determine how much of the disease a patient understands.
 

Information Is Giving Out, Communication Is Getting Through

Back in May of 2012, the United States Preventive Services Task Force (USPSTF) examined the use of PSA screening and concluded that the harms associated with the overtreatment of prostate cancer outweighed the benefits of its early detection. The USPSTF issued a “grade D” recommendation, which is a recommendation against the use of PSA-based screening for men of all ages.

Researchers at the University of Texas Southwestern Medical Center in Dallas used electronic medical records at their institution to analyze real-world data on PSA ordering and referral practices between January 2010 and July 2015. They reviewed 275,784 unique ambulatory visits for men and found 54,684 evaluable PSA orders. Primary care providers ordered 17,315 PSA tests and 858 urology referrals.

Over the 5-year study period, the number of PSA tests per ambulatory visit, the number of referrals per ambulatory visit, the age at the time of the urology referral, and the proportion of PSA tests performed outside the recommended age range did not significantly change.

The researchers concluded that despite the USPSTF recommendation in 2012 to avoid routine PSA testing, clinicians at the institution studied continued to use the PSA as a screening tool for prostate cancer. Although these results cannot be generalized to other healthcare institutions, their findings suggest that clinicians at other institutions also may be continuing to order this test.

 Hutchinson R, Akhtar A, Haridas J, et al. Testing and referral patterns in the years surrounding the US Preventive Services Task Force recommendation against prostate-specific antigen screening [published online ahead of print September 22, 2016]. 

Use of PSA tests between 2010 and 2012 at University of Texas Southwestern Medical Center did not significantly change despite the 2012 USPSTF recommendation against PSA screenings. 

PSA Screening Continues Despite USPSTF Guidance

For decades, clinicians used some variation of “magic mouthwash” or “miracle mouthwash” to alleviate the discomfort of treatment-induced oral mucositis and reduce the risk of infection. Ingredients generally consisted of an antihistamine, antifungal, analgesic, and a coating agent (usually Mylanta or Maalox) prepared as an oral rinse or “swish and swallow.” Research in the late 1990s then determined that this solution was ineffective and represented an outdated practice.

Researchers at the Mayo Clinic in Jacksonville, Florida noted that a large, multicenter, randomized controlled trial had never been conducted to evaluate the efficacy of the “magic” mouthwash and conducted a phase III trial. The mouthwash used in the study was a diphenhydramine, lidocaine, and antacid (DLA) preparation.  

Patients undergoing definitive head and neck radiotherapy (n = 275) experiencing oral mucositis pain rated at least 4 (on a 1-10 scale) were randomized to receive 1 of 3 treatments: magic mouthwash (DLA), doxepin oral rinse, or a placebo rinse. Doxepin had previously been shown to reduce oral mucositis pain in another sizeable phase III trial.

The primary endpoint was pain reduction, as measured by the area under the curve (AUC) of the pain scale over the 4 hours following a single dose of the rinse. There were significant differences in mean AUC reduction in pain between DLA and placebo (11.7 vs 8.7; 

 = .004), which represented a 35% reduction in pain over the 4-hour test period. Doxepin also was significantly effective in reducing pain compared to placebo (11.9 vs. 8.7; 

 = .01). The study was not designed to evaluate doxepin against the DLA mouthwash, so comparisons between the two cannot be made. Study results were presented at the 2016 American Society for Radiation Oncology (ASTRO) Annual Meeting (abstract LBA-3).

A "magic" mouthwash treatment of diphenhydramine, lidocaine, and antacid proved effective in reducing oral mucositis pain in patients undergoing head and neck radiotherapy. 

Mouthwash Alleviates Oral Mucositis in Trial

Researchers from the Netherlands Cancer Institute and the country’s Diakonessen Hospital noted that although dermatography (medical tattooing) is commonly performed around the world as a component of nipple reconstruction after mastectomy, it is rarely used as an adjuvant to enhance the appearance of scars and skin grafts after surgical procedures.

Indications for dermatography are numerous, the study authors noted, and include primary treatment (eg, burn scars, vitiligo, alopecia of eyebrow or scalp, port-wine hemangioma) and adjuvant treatment (eg, surgical scars, skin grafts, free flaps). Compared with surgical options to improve scar or skin transplant appearance, dermatography is minimally invasive and complications seldom occur.

To analyze the effect of dermatography on the subjective perception of the appearance of scars and skin grafts and quality of life, 56 patients undergoing dermatography in the Netherlands between 2007 and 2015 responded to two questionnaires measuring their scar or graft appearance and their quality of life before and after dermatography as an adjuvant treatment for benign or malignant head and neck tumors. The mean age of the study cohort was 56.5 years, and 42 (75%) were female.

The mean improvement in scar or skin graft perception on the visual analog scale of the modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty before and after dermatography was 4 points. On the modified Patient Scar Assessment Questionnaire, uniform improvement of approximately 1 point across 9 questions was observed. The answers to all patient satisfaction and quality-of-life questions on both questionnaires improved significantly after dermatography.

Researchers concluded that this is the first evidence to suggest that dermatography is an effective adjuvant procedure that improves the subjective perception of scar and skin graft appearance and the quality of life in people with head and neck cancer.

 Drost BH, van de Langenberg R, Manusama OR, et al. Dermatography (medical tattooing) for scars and skin grafts in head and neck patients to improve appearance and quality of life [published online ahead of print September 22, 2016]. 

Although dermatography (medical tattooing) is commonly performed around the world as a component of nipple reconstruction after mastectomy, it is rarely used as an adjuvant to enhance the appearance of scars and skin grafts after surgical procedures.

Study Suggests Dermatography May Be Helpful For People With Surgical Scars

Researchers at the National Center for Health Statistics Division of Vital Statistics reviewed the cancer incidence and mortality rates among American children and adolescents aged 1—19 years, and identified trends during the study period of 1999 to 2014.

The overall cancer death rate among children and adolescents declined 20% from 1999—2014, with all 5-year age groups experiencing declines ranging from 14% to 26%. There was no difference in cancer death rates between white and black children and adolescents, and both groups experienced declines during the period.

Cancer death rates continued to be higher for males aged 1—19 years compared with their female counterparts. More than one-half of all cancer deaths among children and adolescents aged 1–19 years in 1999 and 2014 were attributable to either leukemia or brain cancer.

However, a shift occurred during the period, with brain cancer replacing leukemia as the leading type of cancer causing death among children and adolescents aged 1—19 years. The change reflects a reduction in deaths from leukemia rather than an increase in deaths from brain cancer. The full CDC report is available 

Brain cancer has replaced leukemia as the leading type of cancer causing death among children.

Lisa Schulmeister, MN, RN, ACNS-BC, FAAN