A 20-year-old married female presents to the emergency room with a white blood cell count of 800,000. She informs the medical team she is 10 weeks pregnant and shortly after begins to complain of abdominal pain. After a rapid and extensive workup, the medical team informs the patient she has suffered a miscarriage and possibly has newly diagnosed leukemia. After moments of sobbing with her husband, the patient looks up at the physician and says “This was my miracle baby. Will I be able to have another baby?”

The ability to conceive and have a child is often on the minds of patients during childbearing age when they are diagnosed with cancer. Chemotherapy, radiation, hormone therapy, and even stem cell transplantation has the ability to cause infertility. These therapies can interfere with uterine function, prevention of ovaries from being released, and/or fetuses from being carried full term leading to miscarriage. In men, these drugs can impact their erection and ability to produce semen. Drugs such as busulfan, carmustine, cyclophosphamide, doxorubicin, melphalan, thiotepa, and vincristine are commonly given in high doses that can cause permanent damage to fertility. Hormones such as Tamoxifen can interfere with the ability to have children as well as induce birth defects. Targeted therapies such as bevacizumab (Avastin) can lead to permanent ovary damage and thalidomide can cause birth defects. And finally prior to stem cell transplantation, high dose chemotherapy and radiation are given which lead to a disruption eggs from being released from the ovaries.

The American Society of Clinical Oncology recommends those with cancer discuss the risk of infertility and preservation prior to starting chemotherapy. Even if the medical and nursing staff do not initiate the conversation, it is important that patients advocate for themselves to ensure they are equal partners in their care. Those who choose not to discuss their fertility prior to therapy may still have children after treatment however they should wait one year before conceiving. In the event, a patient is pregnant at diagnosis, therapy can be given to preserve the fetus until safe to electively deliver with minimal risk.

So, is chemotherapy an emergency? Not necessarily.

American Cancer Society. How cancer and cancer treatment can affect fertility in females. Retrieved from 

https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/fertility-and-sexual-side-effects/fertility-and-women-with-cancer/how-cancer-treatments-affect-fertility.html#references

American Society of Clinical Oncology. (2020). Your fertility and cancer treatment. Retrieved from 

https://www.cancer.net/sites/cancer.net/files/asco_answers_fertility.pdf

National Cancer Institute (NCI). Fertility issues in girls and women with cancer. Accessed at 

https://www.cancer.gov/about-cancer/treatment/side-effects/fertility-women

Stephanie Jackson is co-editor in chief of Oncology Nursing News and a nationally board-certified clinical nurse specialist specializing in oncology and bone marrow transplantation. She is currently the clinical nurse specialist for the hematology/stem cell transplantation units at a large academic medical center in Los Angeles, California. She has over 2 decades of nursing experience which includes various positions such as acute care, ambulatory, academia, home health, and hospice. She is a member of several professional nursing and community organizations. Some notable mentions include the National Council of Clinical Nurse Specialist, Association of Clinical Nurse Leaders and Oncology Nurses Society. She is the former president of the Greater Los Angeles chapter of Oncology Nursing Society and is currently pursuing her doctorate at Grand Canyon University in Phoenix, Arizona. It is without doubt that her passion for oncology patient stems from her own experience and survival of childhood cancer. 

Articles

Is Chemotherapy an Emergency When Fertility Is at Risk?

Zoom and other videoconferencing methods have become the technological platform used by many organizations in health care to maintain clinical operations. Despite videoconferencing’s many benefits, users are complaining of headaches, ocular pain, fatigue, and more. Those in leadership positions struggle to find balance between connecting with others and transitioning meetings to Zoom in an effort to reduce the spread of coronavirus disease 2019. This phenomenon has become known as “Zoom fatigue” and has led to increasing amounts of stress during the pandemic.1

Practitioners also may feel increased stress because of the minimal time and training they had before making the switch to videoconferencing. Being on camera and maintaining “Zoom etiquette” can be challenging and impersonal, especially among people who have not previously communicated with each other. The fear of failing technology or operating the equipment incorrectly can produce anxiety, another aspect of Zoom fatigue that can be mentally exhausting. Steps to take to decrease fatigue from being on a computer all day include the following:

• Avoid multitasking and be fully present during meetings.

• Put a “Do not disturb” note on your door. This will prevent sensory overload and maximize your ability to focus.

• Make small adjustments to how you are seated or standing to keep your blood circulating. Sitting in the same location for extended periods may lead to increased fatigue.

• Schedule meetings at least 30 minutes apart. This small gesture can not only minimize headaches and ocular pain, but also will increase your attention span during each meeting.

Taking care of yourself is as important as your productivity during the pandemic. It is your responsibility to put you first and maximize your coping in order to endure this new normal.

1. Maheu, M. Zoom fatigue: What you can do about it. Telebehavioral Health Institute. August 29, 2020. Accessed September, 2020. 

https://telehealth.org/blog/zoom-fatigue-what-it-is-what-you-can-do/

Whether staring at a screen for hours or worrying about learning technologies, nurses face new challenges with videoconferencing.

Handling "Zoom  Fatigue"  Amid Constant Videoconferencing

Since the onset of the outbreak of the coronavirus 2019 (COVID-19), health care providers — particularly physicians and nurses – have continued to sacrifice their own health for the sake of their patients. Despite the fact that more than 600 frontline workers that have died of this illness, they still work long hours, often wondering if their efforts will improve the outcomes of their patients. They internally fear being exposed and risk their personal health and that of their love ones upon returning home. On their days off, they continue to adhere to the personal protective equipment guidelines and limit contact with their family despite just wanting to have self-care.

But yet one may say “that’s what they signed up for.” But is this what we signed up for? Has anyone stopped to inquire how we feel? If you asked anyone in the medical field why we keep going, the answer would probably be “because we care.”

Research has shown that those who work in high-risk departments have close contact with patients greater than 12 times a day, and do not adhere to the appropriate protective equipment have a significant risk for challenges to their own health.

 These challenges include skin damage related to prolonged PPE requirements, depression, anxiety, and distress. Three strategies that are highly recommended to assist the mental well-being of healthcare workers during these stressful times include:

 We don’t know when this will end so it is best to pace yourself. Do your best for each patient so when you leave your shift there will be no regrets.

. It can be frustrating working long hours, not having appropriate PPE and being asked to do extra when others are working from home. Acknowledge your frustration and do not hold your anger inside. Holding in your feelings can lead to depression.

 We did not sign up to be a hero. We signed up to serve and assist our patients during their time of illness through restoration of their health. Prolonged stress during this season can be very exhausting. Let others help you and don’t feel guilty for it. There are people who take pleasure in helping frontline workers to ensure we have what we need personally to care for others.

Thank you to all the healthcare workers who care. It is not easy to keep sacrificing your life, health, and well-being for others however the labor is greatly appreciated.

1. Shaukat, N., Ali, D.M. & Razzak, J. Physical and mental health impacts of COVID-19 on healthcare workers: a scoping review. Int J Emerg Med 13, 40 (2020). https://doi.org/10.1186/s12245-020-00299-5

2. Sobel, S. (2020). Top 10 Coping Strategies for Hospital Health Care Workers. Retrieved from https://www.psychologytoday.com/us/blog/successful-psychiatry/202004/top-10-coping-strategies-hospital-health-care-workers.

Frontline workers need self care now more than ever.

Nursing In a Pandemic: Is This What We Signed Up For?

A 26-year-old male with acute myeloid eukemia is admitted for treatment of refractory disease. He begins treatment with blinatumomab (Blincyto) continuous infusion for 28 days with the option for discharge on day 9, pending symptom management and treatment response. The patient’s only support is his 24-year-old significant other, given his family is working and lives in Las Vegas, Nevada. On day 2, of treatment executive leadership mandates all visitors must cease given the spread of the coronovirus.

A 72-year-old male is scheduled to be admitted for stem cell transplantation for non-Hodgkin’s lymphoma with his darling wife of 50 years. His wife has never left his side for the past years and has been a significant partner in his successful treatments. The patient has only agreed to undergo transplant knowing his wife will be present each step of the way. On the day prior to admission, the bone marrow transplant coordinator informs the couple she will be unable to stay to minimize the spread of coronovirus.

What do you respond when the patient says the following? 

“But I have no family nearby and she is my motivation.”

“We’ve never been apart longer than 2 days.”

“But my situation is different. Can’t you make an exception?”

“Doesn’t the hospital realize cancer patients need their family by their side?”

“How long is this decision going to be instituted?”

According to Klompas in 2020, in the midst of the Coronavirus disease we must “bolster our approach to routine respiratory viruses.”

 Historically, respiratory viruses were managed passively. Signs were placed on the door to alert everyone entering the room of the appropriate personal protective equipment to wear. Inconsistent practices were instituted to ensure compliance depending on the department and peer accountability. Masks, alone, were considered enough protection, while providers often forgot that viruses could also be transmitted through feces, eye contact, and the oral cavity. Healthcare workers would come to work sick and not be sent home by unit leadership. Many would be unpaid if they were sent home if they had already exhausted their paid time off.

Given our current climate, we must be intentional with our approach, starting within the admission department through the journey of the patient to the outpatient setting. If each patient throughout an acute care setting has family at the bedside, the modes of transmission are exemplified tremendously. Respiratory viruses infect “10% of the population each year and causes tens of thousands of deaths in the United States each year,” according to a 2018 study.

 It is therefore our responsibility as healthcare workers to ensure the safety of our patients and do what is in their best interest. Although this approach is may not be favorable in the eyes of our cancer patients, they will thank us later for keeping them SAFE.

Klompas, M. (2020). Coronovirus disease 2019 (COVID-19): Protecting hospitals from the visible. 

Rolfes, MA., Foppa, IM., Garg, S., Flannery, B., Singleton, J., Burns, E., Jernigan, D., Olsen, S., Bresee, J., Reed, C. (2018). Annual estimates of the burden of seasonal influenza in the United States: a tool for strengthening influenza surveillance and preparedness. 

Given our current climate, we must be intentional with our approach, starting within the admission department through the journey of the patient to the outpatient setting.

When Relationship-Based Care Is Not an Option

As we make our way into 2020, it is important to reflect on all the opportunities and achievements of last year. As oncology nurses, take a moment to exam your goals for professional and educational development. I challenge you to make this a year of professional growth geared to optimize the care you provide patients and families.

Did you know that, according to the Leukemia & Lymphoma Society, every 3 minutes, someone receives a diagnosis of a blood cancer, which accounts for 10% of all cancers? In 2019, an estimated 176,200 people were predicted to receive diagnoses of leukemia, lymphoma, and multiple myeloma. Among these cases, 56,770 were expected to die as a result of their disease.

Given these statistics, conferences such as that of the American Society of Hematology (ASH) are held each year to educate clinicians and scientists working in the field of hematology. In December 2019, ASH celebrated its 61st anniversary, which included recognizing evolutions in acute and chronic leukemia, multiple myeloma, lymphoma, stem cell transplantation, chimeric antigen receptor (CAR) therapy, and many more.

The E. Donnall Thomas Lecture and Prize was awarded to Philip Greenberg, MD, for his research using T cells to treat patients with acute myelogenous leukemia (AML) and solid tumors. For over 3 decades, the only curative treatment for AML has been conventional chemotherapy and allogeneic transplantation. According to the National Cancer Institute, the 5-year survival of patients with AML is 27.4 %.

Innovations such as adoptive cell therapy offer promising outcomes, given their selectivity to T-cell receptors.

Other exciting advancements in the field include the following:

Blinatumomab (Blincyto), a bispecific T-cell antibody, was proved to be effective in sustaining diseasefree survival, overall survival, and the ability to proceed to transplantation in relapsed/refractory (R/R) acute lymphoblastic leukemia.

The bispecific humanized immunoglobulin that targets CD3 and CD20, mosunetuzumab, showed an overall response rate of 64.1% and a 42.2% complete remission rate in patients with indolent non-Hodgkin lymphoma who were re-treated with the agent after CAR T-cell therapy.

A phase I study of CAR T-cell therapy for patients with R/R multiple myeloma showed a median response of 28.8 weeks.

The field of oncology is rapidly expanding with clinical trials, newly approved pharmacological agents, and precision medicine. As nurses approach the future, a commitment to lifelong learning will be essential to remaining competent. We will need to provide multimodal teaching to ensure that patients understand their treatments, including adverse events. Patients and families depend on their nurses to be knowledgeable experts in their care.

The evolution of population health has expanded the settings in which oncology patients receive treatment. These settings include hospitals, outpatient clinics, and day treatment centers. It is essential that nurses anticipate the needs of patients who receive treatment in nontraditional settings. This includes offering comprehensive discharge instructions, providing emergency contact information, and discussing which symptoms to report. Given the advanced age and complexity of patents with cancer, ongoing reinforcement of the treatment plan is critical to minimizing complications that lead to increased mortality.

Facts and Statistics. Leukemia & Lymphoma Society website.lls.org/facts-and-statistics/facts-and-statistics-overview/facts-and-statistics. Published 2019. Accessed January 3, 2020.

Cancer stat facts: leukemia — acute myeloid leukemia. National Cancer Institute website. 

Brown PA, Ji L, Xu X, et al. A randomized phase 3 trial of blinatumomab vs. chemotherapy as post-reinduction therapy in high and intermediate risk (HR/IR) first relapse of B-acute lymphoblastic leukemia (B-ALL) in children and adolescents/adults (AYAs) demonstrates superior efficacy and tolerability of blinatumomab: a report from Children’s Oncology Group Study AALL1331. Presented at: 61st American Society of Hematology Annual Meeting & Exposition; December 7-10, 2019; Orlando, FL. Abstract LBA_1. bit.ly/2LDMr7U.

Schuster SJ, Bartlett  NL, Assouline S, et al. 

Mosunetuzumab induces complete remissions in poor prognosis non-Hodgkin lymphoma patients, including those who are resistant to or relapsing after chimeric antigen receptor T-cell (CAR-T) therapies, and is active in treatment through multiple lines.

 Presented at: 61st American Society of Hematology Annual Meeting & Exposition; December 7-10, 2019; Orlando, FL. Abstract 6. ash.confex.com/ash/2019/webprogram/Paper123742.html.

Li C, Mei H, Hu Y, et al. A bispecific CAR-T cell therapy targeting Bcma and CD38 for relapsed/refractory multiple myeloma: updated results from a phase 1 dose-climbing trial. Presented at: 61st American Society of Hematology Annual Meeting & Exposition; December 7-10, 2019; Orlando, FL. Abstract 930. bit.ly/38imXXG.

"As nurses approach the future, a commitment to lifelong learning will be essential to remaining competent."

Stephanie L. Jackson, MSN, RN, AOCNS, BMTCN

Articles

Is Chemotherapy an Emergency When Fertility Is at Risk?

Handling "Zoom Fatigue" Amid Constant Videoconferencing

Nursing In a Pandemic: Is This What We Signed Up For?

When Relationship-Based Care Is Not an Option

Nurses, Set Goals in the New Year