		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

One of the great mysteries in oncology practice is the return of breast cancer many years after its initial diagnosis and treatment. And by many years, I mean 15 or even 20 years later, at a time when a woman least expects it to return.

Many women are shocked by a breast cancer recurrence, and often say, “But I thought I was cured.” Some of these women thought they were cured when they surpassed the 5-year mark and were even more confident that cancer would not recur when a decade had passed. However, we now know that “cured” is not the best word to use for breast cancer—or any other cancer for that matter, and instead we need to make note of the number of “cancer-free” years postdiagnosis.

More effective therapies and a better understanding of the genomics of breast cancer have led to improved survival rates, and the relative survival rate at 10 years is now 83%. At 15 years, it’s 78%. As a result, the number of breast cancer survivors is growing. However, for some, breast cancer recurs. Breast cancer that comes back within 5 years of diagnosis is called an early recurrence, and breast cancer that comes back 5 or more years later is a late recurrence.

Local recurrence occurs when the cancer recurs in the same localized area of the breast (ipsilateral) as the first tumor, or in the mastectomy/lumpectomy scar. Two-thirds of breast recurrences have been identified as being local recurrences. When breast cancer appears in a different quadrant of the breast or in the other breast (contralateral), it is usually a new tumor. A regional recurrence occurs when the cancer has recurred in the nearby lymph nodes (eg, axillary, subclavicular areas), and a distant recurrence refers to cancer that appear in distant sites, such as the lungs, liver, brain, and bone. Part of the challenge is determining whether a second appearance of breast cancer is a recurrence or a new cancer.

The likelihood of a breast cancer recurrence depends on several factors, including the size of the original tumor, the number of involved lymph nodes, hormone receptor type, the histologic and nuclear grade of the tumor, and how well the woman responded to her first course of treatment. The risk of distal recurrence is the same for women who had a mastectomy or a lumpectomy plus radiation therapy.

Women diagnosed with breast cancer at a younger age have a greater chance of recurrence than those diagnosed at an older age. Even with the recent advances in breast cancer treatment, women under the age of 50 are more likely to experience a local recurrence than women over age 50. Women with 

 gene mutations are also at a higher risk for contralateral breast cancer after having been diagnosed and treated for an initial breast tumor compared with those who do not have these mutations.

Triple-negative breast cancers have a high risk of recurrence, especially for distant recurrences, compared with receptor-positive tumors. Continuing tamoxifen for 10 years, rather than 5 years, was found to further reduce the risk for recurrence, especially after 10 years; consequently, 10 years of adjuvant endocrine therapy is now recommended.

Although the majority of breast cancer recurrences are the same histology and hormone receptor status, for some women, the recurrence is different from the initial breast cancer diagnosis. It’s not uncommon for women who were ER/PR-positive to recur with breast cancers that are ER/PR negative, or for tumors that were HER2 negative initially to show evidence of HER2 at recurrence.

Unfortunately, many of the risks for the recurrence of breast cancer cannot be altered. The bottom line is that despite the many successes in treating breast cancer, not as much is known about recurrent breast cancer, other than that it can appear in almost any location in the body and at any time after initial treatment—even decades later.

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One of the great mysteries in oncology practice is the return of breast cancer many years after its initial diagnosis and treatment. And by many years, I mean 15 or even 20 years later, at a time when a woman least expects it to return. 


Breast Cancer Recurrence ... Many Years Later

How can it be lung cancer? asked my neighbor. I don’t smoke. My 36-year-old neighbor added that she’s never smoked, and in fact, has never even taken a single puff of a cigarette.

The American Cancer Society estimates that of the 221,200 new cases of lung cancer which will be diagnosed in the United States this year, 105,590 are women,

 and of these, 1 in 5 are women like my neighbor—“never-smokers”&mdash;those who have literally never lit up or who have smoked fewer than 100 cigarettes in their lifetime. Over the past decade, lung cancer among never-smokers has increased 33%, and if lung cancer in nonsmokers was its own category, it would rank among the ten deadliest cancers in the United States.

Only 15% of lung cancers are diagnosed at an early stage, and for many young women who are nonsmokers, like my neighbor, lung cancer symptoms often are initially attributed to something other than lung cancer. My neighbor had been treated with antibiotics for over a month for what her primary care physician thought was an upper respiratory tract infection.

She told me that when healthcare providers see the diagnosis of lung cancer in her medical record, they ask her if she’s still smoking. “I want to scream that I’ve never smoked!” she tells me. The American Cancer Society reports that people with lung cancer often are judged negatively—by both the public as well as some healthcare providers&mdash;because lung cancer is so strongly linked to smoking. Even people with lung cancer who have never smoked may be subjected to this stigma.

The causes of lung cancer among never-smokers are not fully understood. According to the US Environmental Protection Agency (EPA), the leading cause of lung cancer in people who have never smoked is exposure to radon gas. Radon occurs naturally outdoors in harmless amounts, but can become concentrated in houses built on soil with natural uranium deposits. The risk of lung cancer is higher for people who have lived for many years in a radon-contaminated house. Because radon gas cannot be seen or smelled, the only way to know if excessive radon levels are present is to test for it.

Both the EPA and the Surgeon General recommend testing all houses below the third floor for radon, and test kits are available online, at home improvement stores, and via the National Radon Program Services at Kansas State University (

). It’s thought that about 20,000 deaths per year are caused by radon-induced lung cancer.

Each year, an estimated 3400 nonsmokers die of lung cancer as a result of breathing secondhand smoke. For many nonsmokers, this exposure occurs in the workplace. Laws that ban smoking in public places are expected to reduce the prevalence of secondhand smoke, and will likely reduce the incidence of lung cancer caused by secondhand smoke. Other workplace-related causes of lung cancer include exposure to asbestos and diesel exhaust. Work-related exposure to these carcinogens has decreased in recent years as a result of increased governmental and industrial measures to protect workers. It’s also thought that both indoor and outdoor air pollution increase the risk of lung cancer among never-smokers.

Lung cancer among never-smokers is twice as common in women compared with men. Genetic mutations associated with non-small cell lung cancer in non-smokers (EGFR. ALK, and ROS1 mutations) are more common among women than men, and these mutations are associated with a more favorable prognosis and a better response to treatment with targeted agents.

My neighbor has been diagnosed with adenocarcinoma, the most common type of lung cancer found in young, nonsmoking women. By the time it was diagnosed, it had spread to her liver. The 5-year survival rate for metastatic lung cancer is a dismal 4%.

The average age of a lung cancer diagnosis is 70. Only 2%-3% are younger than age 40. Several studies are in the works to better determine how and why lung cancer occurs in young, nonsmoking women. My neighbor does not have single risk factor for lung cancer, and wonders why it happened to her. Her oncologist told her that we now know that anyone with lungs is at risk for lung cancer.

1. American Cancer Society. What are the key statistics about lung cancer? 

http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-key-statistics

How can it be lung cancer? asked my neighbor. I don't smoke. My 36-year-old neighbor added that she's never smoked, and in fact, has never even taken a single puff of a cigarette. 


Young Women, Never-Smokers, and Lung Cancer

Nearly everyone working in the infusion suite is either crying or wiping away tears. A nurse tells me that Melinda has died.

Melinda is the pet therapy dog, who for the past couple of years, has provided companionship in the infusion suite every Friday. Melinda never missed a day of “work” and now she’s gone.

Some of the staff are surprised at how affected they are by the dog’s death and are angry that other staff members say “she’s just a dog” and go about their jobs as if nothing has happened. The death of the beloved pet therapy dog also affects the patients who had bonded with Melinda. Staff needed to acknowledge the patients’ grief, as well as their own.

It is well-known, and scientifically proven, that interactions with gentle, friendly pets are beneficial. These interactions lower blood pressure, release endorphins that induce a calming effect, decrease feelings of isolation, encourage communication, and provide comfort. Data also suggest they may reduce pain and lessen depression.

The bond between a pet and its owner can be strong, and in some cases so strong that the death of a pet is just as devastating as the loss of human life. The Huffington Post reported “10 Ways That Losing a Pet is Worse Than Losing a Human,” and Former president Bill Clinton told Newsweek in 2002 that the death of his dog, Buddy, who was hit by a car, was “by far the worst thing” that Clinton had experienced after leaving the White House. The sudden death of a pet may be especially traumatic.

The infusion suite staff decided to start asking about patients’ pets when they conducted new patient interviews, and started asking current patients about their pets during chemotherapy treatments. Staff reported that the patients “lighted up” when they talked about their pets, and it became clear to the staff that many of these patients thought of their pets as family. Some of the nurses noted the names of patients’ pets in the patients’ medical records, and made it a point to ask about the pets during subsequent visits. These nurses reported that the patients appeared to genuinely enjoy giving updates on their pets, and some patients even provided these updates without prompting from the staff.

Before long, including pets in conversations about family became routine in the infusion suite. A couple of months later, a patient’s cat died unexpectedly, and the staff found themselves providing grief counseling to the patient. The cat’s death also rekindled memories of Melinda’s death.

In the months that followed, other pets died, and the staff observed that the intensity and longevity of grief following a pet’s death can vary widely. One of the nurses researched how to support pet owners following the death of a pet, and found that talking about the pet is therapeutic. Other helpful advice includes strengthening positive memories, finding solace from one’s own spiritual beliefs, and seeking support from individuals and resources. Several veterinary schools and nonprofit animal organizations around the United States have pet loss support hotlines. There also are online forums for pet loss support, books, and online information on pet loss, as well as grief counseling specifically for pet loss.

Actions that are not considered to be helpful include encouraging the pet owner to get a new animal right away, since this may be perceived as “replacing” the pet, and pet owners need time to grieve. Advising the bereaved to “just get over it” devalues the importance of the pet, pressures the pet owner to bottle-up emotions, and impedes the grieving process.

Supporting patients through the death of a pet is likely a role that oncology nurses don’t think much about. However, considering how important pets are in the lives of their owners, nurses can provide holistic care by including patients’ pets in their assessments and conversations.

VIPs include very important pets, as well as very important people.


The VIPs in Our Patients' Lives

Like many nurses, I look at the veins in the forearms of cashiers, restaurant servers, and any other arms that appear in front of me, and lately I’ve noticed that many people are wearing a fitness tracker on their wrists. These devices have exploded onto the marketplace and some predict that they’re in their infancy and will become even more sophisticated in the future. They’ve also become addictive; we all know people who check their fitness trackers until they’ve reached the magic 10,000 steps in a day.

In addition to tracking the number of steps a person takes in a day (and in a week and longer), many of the trackers also perform monitoring functions, such as tracking heart rate and sleep quality. Wireless syncing allows the data to appear on a smartphone or computer. There are even scales that transmit a person’s weight directly to another device, and this information can be stored and/or sent on to healthcare providers.

The Health Research Institute of PricewaterhouseCoopers (

) surveyed consumers and found that one in five owns wearable technology, and about half wear the technology every day. The survey found that the top three pieces of information consumers want from wearables are health-related: 77% want wearables to increase activity, 75% want them to collect and track medical information, and 67% want wearables to help them eat better. Adopters of wearable technology tend to be younger, more affluent, and tech savvy. However, the survey also found that 80% of the general population is familiar with at least one wearable device on the market today.

Potential benefits of wearable technology include reducing obesity, improving sleep quality, prompt detection of health issues, and ongoing monitoring of vital signs or medication adherence, for example. However, experts note that information without action is meaningless. Wearable technology is only effective when people act on the information provided. Drawbacks and concerns about this technology include vulnerability to security breaches, dependence on technology, and further decline in personal social interactions. In healthcare, this could mean fewer in-person clinic visits, as patients transmit health data to their healthcare providers and receive a response electronically or by phone.

Employers and insurers are taking notice of the impact of wearable technology. Some have begun to pay for the technology, or incentivize it (eg, the employee is reimbursed for a fitness tracker after walking a required distance). The Walgreens pharmacy chain has a program where customers can transmit their fitness data to Walgreens in exchange for points that can be used in the stores to buy products. The Apple Watch, equipped with a heart-rate sensor and accelerometer, has an activity app that tracks minutes standing and calories burned, and has a workout app, which provides information about activity. A companion app on the iPhone shares the data with researchers.

Some of the wearable technology products in development with applications to healthcare include the Google X smart contact lens, which has a tiny electronic circuit and microchip embedded in the lens that measures the person’s blood sugar level in tear fluid and transmits the data to a smartphone or other device. The Google X nanoscale “cancer hunters” are nanoparticles in a pill that make their way into the bloodstream to attach to cancer cells. Patients wear a device that creates a magnetic field that pulls the particles to a place where they are counted.

The Sunfriend is a watch-like device that measures UVA and UVB exposure, which has the potential to decrease skin cancer incidence. HyGreen and Biovigil are devices that are in development to improve hand hygiene compliance and effectiveness by “reading” hand cleanliness. The Propeller Health GPS-enabled inhaler has location sensors to track the time and place of each use of the inhaler, and provides data to better identify asthma attack triggers. We can expect to see these devices, and more, in the future.

Potential benefits of wearable technology include reducing obesity, improving sleep quality, prompt detection of health issues, and ongoing monitoring of vital signs or medication adherence.
 

More Patients Tracking Health Data With Wearable Technology

It’s hurricane season again for those of us who live in hurricane-prone areas, and time for us to review our preparedness plans. We all need to be prepared for weather-related events, regardless of where we live. No one is immune from a severe rainfall or snowstorm, ice storm, flooding, earthquake, tornado, or heat wave.

Oncology treatment centers have flooded from raging rivers, as well as from broken pipes inside the building. Major snowstorms have kept patients and staff in the facility overnight. One nurse I know remembers stepping over a deep gap in the floor, caused by an earthquake, when evacuating patients.

We’ve all heard the saying “Prepare for the worst,” and it’s good advice when planning for the unexpected. In cancer treatment centers large and small, it’s best to be proactive and have a defined plan.

The first step is to identify the kinds of events that have the potential to affect your facility, keeping in mind that fires can be caused by things other than wildfires and power outages can occur even in the nicest weather. Consider every possibility, no matter how remote it may seem. Next, list some immediate actions, followed by short-term actions, and then long-term actions. Include the key players—patients, people accompanying the patients, and staff&mdash;and don’t overlook others who might be in the facility, such as delivery personnel, volunteers, and even pet therapy animals.

Immediate actions may involve evacuation of a treatment area, or even evacuation of the building. It’s imperative that facilities have an evacuation plan that includes a variety of scenarios, such as evacuating in darkness, using the stairways instead of elevators, or evacuating without the assistance of first responders, which could be necessary if a widespread disaster occurs.

Depending on the situation, the short-term plan may be to shelter in place. In this scenario, what resources are available—or might not be available&mdash;to patients, staff, and others? Think first about basic needs, such as food, water, shelter, and toilets. Is enough food available or accessible to feed the group overnight? Is there sufficient drinking water on hand? If the power goes out, and there is no heat or air conditioning, how will patients be kept warm or cool? If the sewage system stops working, what is the plan?

The short-term plan also may involve continuing cancer treatment somewhere else, until repairs are made and/or the facility is safe to return to. Logistically, moving the treatment area is a huge project and requires careful planning. Larger facilities generally have more resources than small ones, but even in small facilities there are options, such as contacting other small oncology providers or community hospitals to identify resources. For example, when a small oncology practice flooded when a pipe froze and broke, another oncologist invited the practice to use his office in the afternoons.

Longer-term plans may involve a move to a new or different facility, and in some cases, permanent transfer of patient care to new providers. This occurred in New Orleans, where I live, after Hurricane Katrina. It was not uncommon for patients to resume cancer treatment in facilities far from home. In many cases, though, patients did not have their medical records, and in some cases, had limited knowledge about their disease and treatment history. Complicating the situation was the inability to contact the patient’s provider, since cancer treatment facilities in New Orleans were shut down for weeks, and some never reopened. Remote access to electronic medication records is now more commonplace, and essential for oncology providers in disaster-prone areas.

Disaster plans also need to include staffing considerations. In the event of a widespread weather event, staff may want to leave to check on their families and homes. How will staff respond if patients and others—including staff&mdash;are injured during the event? It’s a lot to think about, and not at all pleasant; however, a well thought-out plan prepares and reassures the staff, comforts the patients, and minimizes cancer treatment interruptions and delays.

In cancer centers large and small, it's best to be proactive and have a defined disaster preparedness plan.

Preparing for the Unexpected

We’ve all heard “back in the day” stories about hazardous drug preparation and handling. Those of us who have been around a while remember the days of preparing chemotherapy in unventilated medication rooms, where we could tell what had previously been mixed in there just by looking at the colored streaks on the wall. Back in those days, we even shared tips on how to remove doxorubicin stains from white uniforms.

Early guidelines had the words “refrain from eating, drinking, smoking, and applying cosmetics while preparing chemotherapy.” We laugh now, but the reason these words were included is that hazardous drug preparation is exactly that—hazardous. We now know that exposure to these drugs can cause acute symptoms such as skin and nasal irritation, and long-term exposure has been linked to infertility and miscarriages, genetic changes, and an increased risk of developing cancer.

Hazardous drugs require safe handling—no one is going to argue about that. Although safe handling guidelines have been published by several organizations, their adoption remains elusive. For instance, some nurses forgo wearing protective gowns while administering chemotherapy. Others misuse personal protective equipment (PPE), and reuse a disposable gown all day long&mdash;sometimes all week long. Some would argue that misuse of PPE may be as hazardous as not using PPE at all.

Having administered chemotherapy as long as I have, I understand their actions. There was a time when chemotherapy infusion bags were spiked at the chair or bedside, so there was a risk of hazardous drug exposure when spiking the bag and then priming and connecting the tubing. However, chemotherapy infusion bags now are routinely primed with saline, so the risk of exposure while assembling the infusion system is virtually eliminated.

Safety experts argue that the tubing spike could fall out of the chemotherapy infusion bag as it is being hung or once it’s hanging on the IV pole. Aside from the fact that the RN should be checking the security of the tubing prior to hanging the bag on the pole, if there is concern that the chemotherapy could shower down on us from the IV pole, then the guidelines should include wearing rubber caps and other PPE to protect the tops of our heads. However, how practical is this? What we need now are hazardous drug handling guidelines that are evidence-based, acceptable to users, easy to implement, and cost-effective.

In other words, what is reasonable, as well as effective?

The Oncology Nursing Society (ONS) hosted a stakeholders meeting earlier this year on handling hazardous drugs, with representatives from the American Society of Clinical Oncology (ASCO), the American Society of Health-System Pharmacists, the Association of Community Cancer Centers, the Association of Pediatric Hematology/Oncology Nurses, and the Hematology/Oncology Pharmacy Association (HOPA) in attendance. A joint position statement that outlines strategies to protect healthcare workers was then developed and approved by ONS, ASCO, and HOPA.

The statement, “Ensuring Healthcare Worker Safety When Handling Hazardous Drugs,” notes that healthcare workers preparing hazardous drugs typically work as employees; consequently, safe handling is a shared responsibility of the employee and employer (Box).

The items listed in the position statement are generic statements, and leave many wondering how to implement the recommendations. The stakeholder group also identified areas for further collaboration, and the group plans to provide resources and tools to promote compliance with implementing safe handling precautions. They also plan to develop resources for using PPE and other safety devices, such as closed system transfer devices, and provide free access to a medical surveillance questionnaire template. These resources will provide valuable guidance to healthcare workers handling hazardous drugs.

		1. Joint position statement from the Oncology Nursing Society, American Society of Clinical Oncology, and Hematology/Oncology Pharmacy Association. Ensuring Healthcare Worker Safety When Handling Hazardous Drugs. https://www.ons.org/advocacy-policy/positions/practice/hazardous-drugs. Accessed April 17, 2015.	

Although safe handling guidelines have been published by several organizations, their adoption remains elusive. 