Fish oil (omega-3) supplements are taken by many patients receiving chemotherapy. A team of researchers in The Netherlands and Japan identified specific platinum-induced fatty acids (PIFAs) that activate splenic macrophages, which in turn led to resistance to chemotherapy in mouse models. Fish oil contains PIFA 16:4(n-3), and when given to mice along with chemotherapy, inactivated the chemotherapy that had been administered.

Four hundred patients with cancer undergoing treatment were surveyed to determine their use of fish oil supplements, and 118 patients responded to the questionnaire. The researchers analyzed the 16:4(n-3) content of 6 fish oils and 4 types of fish, and measured 16:4(n-3) plasma levels in healthy volunteers after ingesting 3 different brands of fish oil or 4 different fish species. Thirty healthy volunteers were randomly selected for the fish oil study, and 20 were randomly selected for the fish study.

Eleven percent of the patients reported using omega-3 supplements. All fish oils tested contained relevant amounts of 16:4(n-3). Mouse experiments showed that the addition of 1 µL of fish oil to cisplatin was sufficient to induce chemoresistance. When the recommended daily amount of 10 mL of fish oil was administered to healthy volunteers, rises in plasma 16:4(n-3) levels were observed, and reached up to 20 times the baseline levels. The researchers concluded that 16:4(n-3) is rapidly taken up in the plasma after ingestion of fish or fish oils. Until further data become available, fish oil and fish containing high levels of 16:4(n-3) may best be avoided on the days surrounding chemotherapy.

Daenen LGM, Cirkel GA, Houthuijzen JM, et al. Increased plasma levels of chemoresistance-inducing fatty acid 16:4(n-3) after consumption of fish and fish oil. JAMA Oncology. April 2, 2015. [Epub ahead of print] doi:10.1001/jamaoncol.2015.0388. 

Articles

Omega-3 may be harmful when taken in conjunction with chemotherapy.

Fish Oil Supplements

I recently stumbled upon the "Humankind" series and other public radio projects that are produced and disseminated through Human Media and Connie Goldman Productions. Human Media produces and distributes programs in association with WGBH/Boston, Connie Goldman Productions and NPR.

A 15-minute guided relaxation audio is available at no-cost at 

(click the “relaxation audio” tab). The meditation focuses on mindfulness and controlled breathing to stimulate the relaxation response. The relaxation exercises are guided by a psychotherapist who provides step-by-step, easy to follow instructions. A series of suggestions and visualizations promote the relaxation response, and it’s recommended that guided relaxation becomes a part of your usual routine, rather than used only when needed. The guided meditation was created for use among nurses; however, it’s applicable to patients as well. 

Guided Meditation for Oncology Nurses

I’m always looking for concise, evidenced-based information on integrative medicine. The key word is “concise,” since much of what I find goes into way too much detail on each of the various integrative therapies. I recently stumbled upon the "Humankind" series and other public radio projects that are produced and disseminated through Human Media and Connie Goldman Productions. Human Media produces and distributes programs in association with WGBH/Boston and NPR, so it’s a reputable source of information.

The Search for Well-Being: Treating the Whole Person in the New Health Care Era. A Primer on Integrative Medicine

 is a free booklet that can be viewed online or downloaded, and is available at 

 (click the “free booklet” tab). The 13-page booklet covers the basics, uses simple graphics to compare conventional medicine to integrative medicine, and provides key information about various types of integrative therapies. The booklet is a wonderful starting point for conversations between patients and healthcare providers about integrative therapies.

The Search for Well-Being: Treating the Whole Person in the New Health Care Era. A Primer on Integrative Medicine is a free booklet that can be viewed online or downloaded

Integrative Medicine Resources

		Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

		Louisiana State Health Sciences Center in New Orleans, Louisiana

An oncologist told me he retired because he couldn’t pronounce the names of the drugs anymore. Neither can most of us when a new drug or biologic agent is introduced, and we see the odd spelling of the drug name for the first time. Ever wonder where generic and trade drug names come from?

There is actually a method to the madness. Generic drug names usually describe a drug’s physiological function or its chemical structure. The generic drug naming process was formalized in 1961 when the American Medical Association, the US Pharmacopeial Convention, and the American Pharmacists Association created the US Adopted Names (USAN) Council to select concise generic names. The FDA joined the council in 1967.

The USAN Council names the active ingredients in drugs, biologics, vaccines, and even contact lenses and sunscreens. The council then recommends generic names to the World Health Organization’s International Nonproprietary Names program, which ultimately chooses a single generic name for each new drug that is acceptable worldwide and then used globally. Drug manufacturers are required to obtain generic drug names using this process in order to bring new drugs to market.

Generic names for drugs are constructed with 

 and stems that classify the drugs into different categories and sometimes are used to distinguish drugs within categories. For example, the suffix “mab” indicates the drug is a monoclonal antibody, “ximab” indicates it’s a chimeric antibody that responds to more than one antigen, and “zumab” refers to humanized antibodies.

Drug manufacturers can suggest generic drug names to the USAN Council; however, any name that suggests the drug is superior to or more effective than another drug will not get approved. On occasion, the council approves manufacturer’s requests for proposed generic drug names. For example,  Onyx Pharmaceuticals’ multiple myeloma treatment carfilzomib is named after molecular biologist Philip Whitcome (who was a founder of the company that first developed carfilzomib) and his wife, Carla, who both succumbed to cancer (the “Ph” in Philip was changed to an “f” to make the name compatible with multiple languages). Dasatinib for CML is named for research fellow Jagabandhu Das. In keeping with USAN Council requirements, both of these generic drug names include a suffix that describes the classification of the drug (eg, carfilzomib is a proteasome inhibitor and dasatinib is a tyrosine kinase inhibitor).

Choosing a brand, or trade, name is an entirely separate process, and an interesting one. Historically, trade names incorporated or resembled their chemical or generic names. For instance, the chemical name of Tylenol is N-ace

 so it’s easy to see where the trade name originated. Over time, though, trade names have become largely independent of their generic or chemical names.

The process of developing a trade name for a new drug is complex. The manufacturer’s goal for a new name is that it is distinctive and memorable, while at the same time is not a drug name that looks or sounds like the generic or trade name of a drug already on the market. In addition, the trade name ideally is easily pronounceable; however, with the proliferation of new drugs of all types, this isn’t always possible.

Manufacturers often use creative agencies to come up with new trade drug names, and then use third-party organizations (such as the Brand Institute) to obtain feedback about the proposed trade names. The proposed names are reviewed for similarity to existing drug names, implied unsubstantiated or false claims (for instance, does the drug name imply cure?), and possible name confusion (years ago, a proposed drug trade name was eliminated because it sounded like “the name of one of Santa’s reindeer” to a number of people surveyed).

Once the trade name has been finalized, it’s up to the manufacturer to market the drug and educate clinicians and consumers on how the drug’s trade name is pronounced. Trade names starting with the letter “X” have been especially challenging to pronounce when they’re seen for the first time. Likewise, there are several trade names of oncology agents that are pronounced differently than they look phonetically, which reminds us all of our elementary school days when we were learning how to read.

An oncologist told me he retired because he couldn't pronounce the names of the drugs anymore. 

My Worst Nightmare: A Spelling Bee With Only Oncology Drug Names

As more is learned about the late effects of various types of cancer treatment, we’re better able to anticipate patients’ needs and improve the early detection of these late effects.

Researchers at The University of Texas MD Anderson Cancer Center analyzed data from 7620 adult patients who underwent hematopoietic stem cell transplantation from January 1997 to December 2011 and were followed-up until December 2013 (median follow-up was 85 months). Data included the cumulative incidence of fracture as well as age and gender fracture incidence, which were compared to a control population using estimated rates from the 1994 National Health Interview Survey and the 2004 National Hospital Discharge Survey.

Half (51%) of the patients underwent autologous stem cell transplantation and 49% underwent allogeneic stem cell transplantation. Most (75%) were white and 56% were male and 44% were female. The transplants were done to treat hematologic malignancies (67%), multiple myeloma (22%), and solid tumors (11%, of which 46% were breast cancers and 27% were ovarian cancers).

Fractures occurred in 602 (8%) patients overall, with 11% occurring among those who had an  autologous stem cell transplantation and 5% of those who had undergone allogeneic stem cell transplantation. Fracture incidence rates after hematopoietic stem cell transplantation were significantly greater than those in the U.S. general population in almost all subgroups, and data suggest that patients aged 45-64 were at highest risk. The researchers noted that about half of the patients died before the study concluded, so long term outcome data may have been different had these patients lived longer. The take home message is that this study suggests that long term effects of hematopoietic stem cell transplantation include an increased fracture risk and older patients should be closely monitored.

Pundole XN, Barbo AG, Lin H, et al. Increased incidence of fractures in recipients of hematopoietic stem-cell transplantation. 

published online on March 16, 2015; DOI:10.1200/JCO.2014.57.8195.

Increased risk of bone fracture noted among patients aged 45-64 years.

Late Effects of Transplantation

On March 17, 2015, the American Society of Clinical Oncology (ASCO) released 

The State of Cancer Care in America: 2015

, which describes the current cancer care delivery system and discusses trends that are occurring in the oncology workplace and workforce.

The report builds on findings released last year in ASCO’s inaugural report.

There is an even wider array of treatment options available today than a year ago; four new medical devices and ten new drugs and treatments were approved in 2014. Because of these and other advances, people with cancer are living longer and 68.5% are alive five years after diagnosis (compared to only 49% in 1975). While this number looks good, what’s concerning is the 45% predicted increase in cancer incidence by 2030, largely because of our aging population. Our workforce is older and has plateaued, and is unlikely to meet the growing demand for care. In addition, professional burnout is on the rise, which may translate into reduced working hours or earlier retirement. We also have continued disparities in access to care across racial and ethnic groups, and in rural areas. Practice structures are changing because of increased costs, competition, and the proliferation of cost-containing programs. Practices continue to consolidate, with 25% of community-based practices reporting that they are likely to affiliate with a hospital in the coming year. Lastly, research funding cuts may impact future advances in care.

What are the fixes to the concerns identified? We need more oncology healthcare providers, and especially need more that reflect the population being treated; only 2.3% of practicing oncologists are African American. We need to break down the barriers preventing access to care, and encourage or provide incentives to practice in rural areas. We need to provide cost-effective care, but not if there is an associated burden, such as increased paperwork and reporting. We also need expanded support for cancer research, which has the potential to reduce the cancer burden and improve the lives of our patients. 

The State of Cancer Care in America: 2015 

ASCO's report identifies progress and challenges

Cancer Care in 2015

Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Louisiana State Health Sciences Center in New Orleans, Louisiana

The terminology of aging has changed over the past decade or so, and we’re now using phrases such as young old (aged 60 to 69 years), middle old (aged 70 to 79 years), and the very old (aged 80+). According to the Census Bureau, 5.7 million people in the United States are aged 80-84 and 5.5 million are aged 85 and older. People are now living longer than ever before. In fact, the Hallmark Cards Company sells 85,000 “Happy 100th Birthday!” cards each year.

 is an evolving challenge. The numbers are growing, and with increasing age, come increasing medical problems. It’s not uncommon for an older patient to have heart disease, diabetes, arthritis, and other medical disorders in addition to cancer. These patients are likely to be taking multiple drugs, which may interact with cancer treatment and/or require close monitoring during treatment. The decision to treat—or not treat&mdash;an older patient may be difficult; aging is highly individualized so treatment decisions cannot be made on the basis of age alone. And because the elderly are under-represented in clinical trials, information about how to best treat an older population is limited.

Treatment decisions need to be based on potential benefits and how the patient may be affected by adverse effects. This decision-making can be an ethical dilemma; however, the starting point is considering the patient’s wishes after providing accurate information about risks and benefits of treatment.

Recommending no treatment and offering only symptomatic/palliative care is difficult for many clinicians and may not be an option the patient wants to consider. In reviewing hundreds of medical records over the years, I’ve yet to see a documented discussion of recommending no treatment. Instead, some type of treatment, including giving a “sprinkling of chemotherapy,” has been recommended. It appears it is just too difficult to suggest no treatment. The hesitation may be that no treatment is equated to “doing nothing,” which is not the case. When clinicians are fully informed about and comfortable with the principles of palliative care, there is much that can be done in the absence of cancer treatment.

To assist in decision making about the treatment of cancer in the elderly, we need to carefully examine the likelihood of response to chemotherapy and survival benefit. We also need to consider the physiological changes that accompany aging, such as diminished organ function, which will affect how chemotherapy is metabolized. Impaired heart, lung, kidney, liver, or bone marrow reserve are particularly problematic when giving chemotherapy or radiotherapy. However, when older patients are carefully screened and monitored throughout treatment, adverse effects can be minimized or quickly addressed.

An 11-question survey can be used to assist in determining which older patients can benefit from chemotherapy and which ones are unlikely to tolerate treatment. A tool for assessing chemotherapy tolerance in older patients was developed by Arti Hurria, MD, and the City of Hope Comprehensive Cancer Center. It looks at such risk factors as the patient’s age (72 years or older), hearing, creatinine clearance, hemoglobin levels, number of falls in the last 6 months, and level of social activity.1 A score of 0 to 5 indicates that the patient has a low risk of experiencing severe toxicity from chemotherapy, 6 to 9 indicates about a 50% risk and 10 to 19 indicates a high risk of developing a severe or even fatal reaction to chemotherapy.

The longer Comprehensive Geriatric Assessment (CGA) also is a valuable tool in the assessment of older patients but may be cumbersome to implement for daily clinical use. Regardless of the tool used, care of elderly patients with cancer can be improved by identifying the patients who are best suited for treatment.

Hurria A, Towgawa K, Mohile SG, et al. Predicting Chemotherapy Toxicity in Older Adults with Cancer: A Prospective Multicenter Study; 

The terminology of aging has changed over the past decade or so, and we're now using phrases such as young old (aged 60 to 69 years), middle old (aged 70 to 79 years), and the very old (aged 80+).

Treating Elderly Patients: How Old Is Too Old?

News media have reported the statistic that one in two people in the United Kingdom (U.K.) will be diagnosed with cancer at some point in their lives. Most people seem surprised by this statistic; however, for years now, the likelihood of developing cancer in the U.K., U.S.A, and especially developing countries, has been rather high and continues to rise. In its 2015 publication on cancer statistics, the American Cancer Society (ACS) prepared a table on the lifetime probability of developing and dying from 23 types of cancer.

For men, there is a 43.3% chance of developing cancer at any of the 23 sites, which the ACS states is a “1 in 2” risk. The chance of dying from cancer for men is 22.8% or “1 in 4.” For women, the chance of developing cancer is 37.8% or “1 in 3” and the chance of dying is 19.3% or “1 in 5.” For men, prostate cancer continues to be the cancer most likely to occur, and lung cancer continues to be the type of cancer that causes the most deaths among men. Breast cancer continues to be the most common cancer among women, and lung cancer causes the most deaths. The statistics haven’t really changed all that much, but what has changed is the use of the “one in two people will get cancer” message. Hopefully this has encouraged people to consider ways to reduce their chance of developing cancer, such as quitting smoking, eating a healthy diet, and avoiding obesity. 

Recent statistics predict lifetime probabilities.

Risk of Developing Cancer

How to best deliver bad news has received a lot of attention in the healthcare community. Patients need to be accurately informed but at the same time, is a message of gloom and doom necessary? Researchers in an outpatient supportive care center at a Houston cancer center conducted a randomized clinical trial to examine how information is conveyed and perceived.

One hundred patients were randomized to observe two standardized 4-minute videos of a physician discussing treatment information with a patient with advanced cancer. One version presented a more optimistic message and the second presented a less optimistic message. Both physicians made five empathetic statements and displayed identical posture. After viewing each video, patients completed assessments including the Physician Compassion Questionnaire. Patients reported significantly higher compassion scores after watching the more optimistic video as compared with the less optimistic video. Higher perception of compassion was found to be associated with greater trust in the medical profession independent of message type: 63 patients observing the more optimistic message ranked the physician as trustworthy versus 39 after the less optimistic message. The researchers concluded that patients perceived a higher level of compassion and preferred physicians who provided a more optimistic message. These results are not surprising; however, they also raise concern about framing information so optimistically that patients believe treatment outcomes will be better than they actually are. Patients don’t need to be hammered about a poor prognosis but do need accurate information so that they can make plans for the future.

Tanco K, Rhondali W, Perez-Cruz P, et al. Patient Perception of Physician Compassion After a More Optimistic vs a Less Optimistic Message: :  A Randomized Clinical Trial. 

Published online 2/26/15. doi:10.1001/jamaoncol.2014.297.

Optimistic messages convey a higher level of compassion.

Delivering Bad News

The American Society of Clinical Oncology (ASCO) created the PRE-ACT (Preparatory Education About Clinical Trials) program to provide general information about clinical trials to patients and the lay public. PRE-ACT was developed with support from the NCI and is available on ASCO’s patient education website, cancer.net.

PRE-ACT delivers clinical trial information through a series of 20 short videos. Users can choose to have PRE-ACT personalize the videos based on their feedback to a series of questions that assess knowledge and/or interest areas, or may browse videos of interest from the entire video library. Some of the topics covered in the videos are understanding randomization, who pays for clinical a trial, and how expenses can be managed when transportation to a clinical trial is required.

ASCO notes that that PRE-ACT may assist patients in considering all of their treatment options.

Although the website is accessible to patients (as well as the public), patients need to know it’s there, so I’m hoping that ASCO will publicize the availability of this resource and hope that clinicians will make patients aware of its existence. 

Online patient education program provides short videos.

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