The language used to describe patients in electronic health records (EHR) may be perpetuating racial bias and other negative stereotypes in health care, according to a study recently published in 

 A multi- disciplinary team of investigators from the University of Chicago used machine learning techniques to analyze potentially stigmatizing language across more than 40,000 history and physical notes in EHRs made up of 18,459 adult patients and 33,142 unique encounters at an academic medical center in Chicago, Illinois, between January 2019 and October 2020. They determined Black patients were 2.54 times more likely than White patients to be described in negative terms (95% CI, 1.99-3.24). Negative terms included refused (n = 1461), (not) adherent (n = 605), (not) compliant (n = 561), and agitated (n = 409). Findings were adjusted for sociodemographic and health characteristics.

Moreover, the differences were not solely based on race. For example, Medicare and Medicaid beneficiaries were more likely to have negative descriptors applied to them than were patients with commercial- or employer-based insurance (Medicare: adjusted odds ratio [AOR], 2.08; 95% CI, 1.57-2.75) (Medicaid: AOR, 2.66; 95% CI, 2.08-3.40), as were unmarried patients (AOR, 2.12; 95% CI, 1.70-2.65) compared with patients who were married.

Evaluable patients were patients with at least 1 charted history or physical note in their EHR when they were admitted to an inpatient setting or emergency department or visited an outpatient setting. These notes are designed to document the patient’s reason for seeking medical care; provide a summary of medical, family, and social history; and lay out the prescribed care plan to address the medical problem. The investigators chose to center their research on the history and physical note because it is designed to create a comprehensive narrative of the patient’s experience, which will be used by other health care professionals. If a patient had multiple history and physical notes, all available notes were extracted and included for analysis.

The findings are especially troubling, given that other studies have found that less than 20% of text in inpatient progress notes are original,

 with most of the rest being imported from prior documentation. As a result, “subsequent providers may read, be affected by, and perpetuate the negative descriptors, reinforcing stigma to other health care teams,” the authors wrote. “Negative descriptors written in the admission history and physical may be likely to
be copied into subsequent notes, recommunicating and amplifying potential biases. This practice underscores the responsibility of providers who document the initial patient encounter to do so in an aware and sensitive manner.”

Furthermore, the investigators found that notes written for outpatient visits were less likely to have negative descriptors included in the patient’s EHR than inpatient encoun- ters (31% vs 68%). They theorize that this may result from inpatient settings being inherently more stressful, thereby increasing the risk of doctors using stereotypes as “cognitive shortcuts.” They also found that race-based differences in the use of negative descriptors narrowed after March 1, 2020.

Nevertheless, the authors agreed that fixing the problem will require medical 

institutions to better address the issue of implicit racial bias among providers. They cite the example of 1 physician’s use of the term “aggressive” as reflecting the physi- cian’s personal bias regarding Black men. Once such a negative label becomes part of the patient’s record, “it potentially affects the perceptions and decisions of future providers, regardless of whether future providers hold a bias about Black men being aggressive,” they wrote.

Regulatory bodies, such as the Accreditation Council for Graduate Medical Education, might also develop specific recommendations for the use of nonstigmatizing, patient-centered language to prevent the transmission of bias, they suggest. The study concludes that the need is especially important in light of the OpenNotes policies that medical institutions are adopting, which allow patients full access to their EHRs, including chart notes. Without paying attention to the language used to describe patients, providers risk “harming the patient-provider relationship, with downstream effects on patient satisfaction, trust, and even potential litigation.”

Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: documenting racial bias in the electronic health record.

. 2022;41(2):203-211. doi:10.1377/hlthaff.2021.01423

Wang MD, Khanna R, Najafi N. Characterizing the source of text in electronic health record progress notes. 

 2017;177(8):1212-1213. doi:10.1001/jamainternmed.2017.1548

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Fixing the problem will involve holding medical institutions accountable for addressing implicit bias among providers.

Electronic Health Record Notes May Be Perpetuating Biases

Female cancer survivors are as likely to give birth to healthy babies as women who were not treated for cancer, according to a study recently published in the 

Journal of the National Cancer Institute.

 However, female cancer survivors are more likely to develop a severe complication during pregnancy or labor than those without a history of cancer, the data caution.

Findings showed that female cancer survivors were just as likely as the general female population to carry a pregnancy past 20 weeks (relative risk [RR] = 1.01; 95% CI, 0.98-1.04) and that there was no difference in birth defects or Agpar scores between babies born in the survivor or control group cohorts.

Among more than 4000 cancer survivors, only 87 women (2%) experienced a serious complication during labor or developed a heart problem during pregnancy. Furthermore, cancer survivors were twice as likely to experience these difficulties compared with non-cancer survivors.

At 30 years old, women who had survived cancer had a cumulative incidence of achieving a recognized pregnancy of 22.3% (95% CI, 20.7%-23.9%) compared with 26.6% (95% CI, 25.6%-27.3%) among the general population (HR, 0.80; 95% CI, 0.75-0.86). Risk factors for a lower likelihood of conception included history of a brain tumor, alkylator chemotherapy, cranial radiation, or hematopoietic stem cell transplantation (HSCT).

“The message here is largely positive,” said study leader Paul Nathan, MD, of the Hospital for Sick Children in Toronto, Canada. “Women who have a history of childhood cancer have a really good chance of getting pregnant, and most of them are quite fine through the pregnancy. But it’s super important for the people caring for them to know about these risks.”

Investigators identified 4062 women who had underwent cancer therapy between 1985 and 2012 while they were under the age of 21 years. All evaluable patients were identified via a single-payer health insurance program covering Ontario, Canada. Each patient with a history of cancer was compared with 5 women with no history of cancer. In total, the survivors were compared against 20,308 comparisons women from the general population, totaling in an assessment of over 24,000 women.

Although women who had received treatment were just as likely to give birth to a healthy baby as women from the general population, they were at an increased risk of severe maternal morbidity (RR, 2.31; 95% CI, 1.59-3.37), cardiac morbidity (RR, 4.18; 95% CI, 1.89-9.24), and preterm birth (RR, 1.57; 95% CI, 1.29-1.92). Furthermore, patients who had received allogenic HSCT were more likely to experience a preterm birth (RR, 8.37; 95% CI, 4.83-14.48) as did those who underwent autologous transplant (RR, 3.72; 95% CI, 1.66-8.35).

These results suggest that female cancer survivors may benefit from high-risk obstetric care, although in the United States, ensuring that survivors know to seek these resources could be improved through better communication between providers, noted experts.

“High-risk obstetric care is widely available in most of the country, but childhood cancer survivors may not be recognized as needing that kind of care,” Emily Tonorezos, MD, director of NCI’s Office of Cancer Survivorship, commented on the study. Tonorezos noted that health care providers may not know that their patient was treated for cancer as a child, particularly if they have relocated between cities or states and transferred to a new medical system.

“The burden of making sure you’re getting good health care is very often on the survivor and their family,” added Tonorezos. “That’s not where the burden should be, but survivors need to [make sure] health care providers have some of that information, because sharing data is not built into our health system,” she added.

Nathan agreed that women who were treated for cancer before the age of 21 would benefit from frank conversations with their providers about a potential need for high-risk obstetric care. This high-risk care could encompass heath monitoring throughout pregnancy, as well as frequent fetal monitoring. The key, according to Nathan, will be ensuring that all the providers caring for a childhood cancer survivor understand their medical history.

“Health care providers’ knowledge of a patient’s cancer history can also spur other important conversations about reproductive health,” he said. “[Figuring out] how to share this information with health care providers is going [to be] one of our key goals.”

Overall, however, these findings are promising for cancer survivors, as they suggest that a healthy pregnancy is possible with a little additional monitoring, concluded experts. “The expectation of a healthy pregnancy and a healthy baby should be the norm, even for childhood cancer survivors,” said Tonorezos.

1. Zgardau A, Ray JG, Baxter NN, et al. Obstetrical and perinatal outcomes in female survivors of childhood and adolescent cancer: a population-based cohort study. Published online ahead of print January 19, 2022. 

2. NCI Staff. Good News and cautions about pregnancy for childhood cancer survivors. National Cancer Institute. March 4, 2022. Accessed March 28, 2022. https://bit.ly/3iJyGoA

Childhood cancer survivors may benefit from high-risk obstetric care despite being able to conceive and give birth safely. 

Childhood Cancer Survivors Likely to Deliver Healthy Babies, But May Require Additional Monitoring During Pregnancy 

Today, embryo and oocyte cryopreservation are 2 mainstays of fertility preservation in the realm of breast cancer treatment, according to Lindsay Kroener, MD, an assistant clinical professor in the Department of OB/GYN at UCLA David Geffen School of Medicine.

Kroener recently discussed the topic during the 

, “Answering Your Patient’s Questions About Fertility,” outlined the scope of the fertility preservation in cancer, different treatment options and candidate considerations, and conversations surrounding pregnancy following cancer treatment. In an interview with 

Kroener highlighted how egg and embryo cryopreservation have evolved over the years to represent the most reliable options for patients.

“These treatments are not going to be for everyone. But in terms [of oncofertility], egg and embryo cryopreservation are the best options we have,” she said.

Specialists conduct ovarian stimulation by injecting gonadotropins (FSH/HMG) to stimulate growth in multiple ovarian follicles. These injections are delivered across 8 to 12 days and initiation usually begins on the second or third day of the menstrual cycle. During this time, patients are monitored every other day via an ultrasound and blood work.

When the follicles reach an appropriate size, they receive a trigger shot to induce egg maturation. About 35 to 36 hours later, the eggs are retrieved. This procedure typically occurs in the outpatient setting for about 15 to 20 minutes, and while the patient is under a conscience sedation.

In the case of oocyte cryopreservation, the retrieved eggs are examined microscopically, and the mature ones are cryopreserved. For embryo cryopreservation, oocytes are fertilized with partner sperm on the day they are retrieved and then maintained in a culture for 5 to 7 days. When blastocyst stage occurs (100 cells) the specimen is cryopreserved.

“Those eggs can either be cryopreserved right at that time, or they can be grown out into embryos (if there's sperm to fertilize those eggs),” explained Kroener. “One of the key things [to consider] is [that], as of 2012, cryopreservation is actually considered non-experimental and so it really offers a good option for our non-partnered patients [who no longer need] to say, ‘Hey, I [need to] go find donor sperm to make embryos.’”

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Lindsay Kroener, MD, offers an overview of current fertility preservation options for patients about to undergo cancer therapy. 

Cyropreservation Continues to Improve Fertility Options for Patients with Breast Cancer

Although significant strides have been made to incorporate behavioral therapy into oncology care, gaps in this type of care still exist, explains Matt Iwaniec, PsyD.

, Iwaniec, a licensed clinical health psychologist with the stem cell transplant and CAR-T therapy program at Allegheny Health Network, underscored the value of integrated behavioral health programs and the biggest challenges in helping patients receive this form of supportive care.

 Could you speak to the value of incorporating behavioral therapy into the treatment plans for patients undergoing cancer treatments?

 We know that cancer is one of the most stressful experiences that anyone can go through in life—particularly [with] types of cancer that have a high rate of recurrence. People who are in survivorship for years might be struggling with anxiety and worrying about having a recurrence.

Generally, people are not well prepared to deal with it; it's not something that you learn to cope with or deal with in school. Usually when people receive [a cancer] diagnosis, it comes pretty suddenly. Therefore, people who are working in oncology really need to have an appreciation of that and be aware of that.

Psychologists and behavioral health professionals have a unique skill set that we can bring to the practice of oncology to help patients, families, clinicians, doctors, nurses, teaching assistants, nurse practitioners, etc. deal with the stress of cancer—because it is not just stressful on the patient. It is stressful on the whole family, and it is stressful on the teams that are treating them too.

[I believe] integrated behavioral health care is the way to go for the future. It should be a standard part of treatment for everyone involved in the process.

Could you break down what behavioral health services look like?

There is going to be variability across the board with where patients are receiving treatment. Some people don't have access to behavioral health treatment—particularly in rural areas, there may not be a psychologist or a clinician to see.

In a fully integrated program, [patients] meet with a psychologist on their very first day that they meet with the oncologist and then work with a behavioral health professional throughout their entire [treatment]. The idea is for behavioral health [to] be fully integrated, meaning you get a diagnosis, and you are introduced to the mental health professional who's working in the clinic who has an established relationship with the other people working in that clinic. Then, you can orient them to what behavioral health care looks like, what services are available to them, how they access those services, how often they would see you, what you would be working on, etc.

What is more typical [in traditional institutions] is that people will see an oncologist and they might be screened for some type of emotional distress. Maybe they have symptoms of anxiety or have symptoms of depression, and [therefore] a nurse or provider will refer them to a behavioral health provider that's outside of the clinic—somebody else in the community that they might have a somewhat distant relationship with. They're not working directly together, but they're aware that they're out there and they try to funnel patients into that location.

Then, the patient is kind of responsible for contacting that person; they are [not] getting introduced to that person for some time. That distance creates a barrier to the patient receiving that care, because there's a physical distance, and there's a temporal distance between the time they get the diagnosis and they see the provider. There may be a lot of unanswered questions: Will insurance cover it? How do I arrange transportation? Right now, [unfortunately] there is just great variability in what is available to people and how they access it.

What are some popular behavioral therapies? How can they help improve patient outcomes?

There is a lot of research that supports the use of cognitive behavior therapy [CBT] and acceptance and concomitant therapy (ACT) for cancer-related distress. CBT has been around longer. ACT is a newer form of therapy that grew out of that CBT tradition.

The basis of CBT is that how you are thinking connects with how you are feeling emotionally and physically, and [therefore] what you are doing behaviorally. Thoughts, behaviors, and feelings are all interconnected. If you are struggling emotionally with symptoms of depression, or symptoms of anxiety, those can be influenced by identifying patterns of thinking.

Whenever somebody sees a therapist for the first time, there is usually an intake process where you get to know the person. The psychologist will take a history and [determine] whether [a patient] meets clinical criteria for a mental health diagnosis. Then they will work with the patient to establish a treatment plan.

With CBT, the beginning of that treatment plan is usually education about that CBT model that I just briefly described and then getting the person to understand how this is working for them. CBT is usually highly structured. First, there is an educational component, then there's an agenda for the session. [We establish] what we want to cover for this hour that we're together, and at the end of the session, there's a homework assignment.

For folks first starting out in CBT, that homework assignment is starting to notice and track different situations that come up [through] different thoughts they have in different situations, and then how they respond to those situations and thoughts emotionally and behaviorally so that the person begins to understand or better understand that connection between thoughts, behaviors, and emotions.

Once they're able to understand that and observe [their own thoughts, behaviors, and emotions], then you can start to do more therapeutic work.

[There is something that is common in cancer-related CBT]: people often have a fear of becoming a “burden” to their families, or thinking that their families view them as a burden. Therefore, when situations come up during the week, such as if they need a ride to an oncology appointment, they might think, “I'm a burden,” or “I'm putting ‘so and so’ out,” and then the emotion of sadness or guilt comes up.

Family members are often actually pretty happy to help out because that helps them cope with the person's cancer too. They feel like they're being useful, productive, supportive, etc. They [typically] don't mind doing these things for the patient—it makes them feel empowered, but the patient may not perceive it that way. They feel as if they are a burden.

We help the patient to identify, “This is the thought you're having. This is why you're feeling guilty.” [Then] we look for evidence to refute that, and we help them label those types of thoughts. [We call this] jumping to conclusions.

Somebody can learn to do this on their own in real time. They can notice, “Oh, I'm feeling guilty about this appointment, because I'm thinking of [being] a burden. [But] I think about the evidence and that's not true. What's true is that this person is glad that they can be of assistance.” You can then change the emotional reaction from guilt to one of appreciation or gratitude. This helps the person cope with that situation.

The behavioral part of CBT also [involves] getting people to engage in behaviors that are helpful. Usually, the recipe for that is something that they either enjoy, or something that makes them feel competent. Whenever a patient is dealing with adjusting to cancer,

it's common for people not to be engaging in things that they enjoy, or to feel competent, because of all the chaos that has happened in their life. Therefore, we will plan and schedule activities to help the person fully engage in things that they enjoy or help them feel competent. That boosts people's mood too.

The basics of CBT are really present focused. It’s not what a lot of people imagine therapy to be where they go, and they lay on a couch, and they talk about their childhood. It's about how your actions and thoughts are functioning for you right now and how you can be flexible with them to manage the stress and manage the difficult emotions to the best of your ability.

ACT is a little different. It does focus on thoughts and behaviors like CBT does, but rather than identifying thoughts as “jumping to conclusion,” and then challenging them with evidence, we teach people our mindfulness skills to take a step back when they notice that is happening, unhook from it, and to accept the reality. [To accept] that this is a thought that I have right now in this situation. Then we are fully engaged with behaviors that they value. Although someone might think that they are a burden, we can [now] understand where that [feeling] comes from, let it be there, and then turn our attention to having a conversation with somebody that you love about something that is important to you.

What challenges have you faced with some of these therapeutic approaches?

The biggest challenge for these therapies is incorporating them into what the patient is already having to deal with. They’re feeling ill, they're feeling fatigued. They're feeling anxious and they're oftentimes not sleeping well. They have a lot of appointments, tests, and this can feel like just another thing that [they] have to do on top of everything else that [they] have to do to deal with this cancer.

The therapist tries to address that challenge by using motivational interviewing to get the person to realize how doing this little extra bit of work will benefit them in the long run, how it is in line with what they want and what they need and their reasons for doing it, and then reinforcing how it's helpful.

Generally, the 2 biggest challenges for engaging people in these therapies in the cancer world are access—being able to connect the therapist with the patient—and then helping [patients] do [their] own therapeutic work between the sessions with everything else that they have going on.

In recent years, how have the emotional and mental needs of patients alongside their physical treatments been addressed?

There is definitely a greater appreciation for the need. Consequently, there has been more dedication of time and resources to hiring mental health professionals, trying to get them integrated into clinics, trying to treat the patient as a whole person every time we have a connection with that patient, etc.

The move has certainly been away from like a strictly medical model toward appreciating the patient as a holistic individual that has these behavioral health needs. Attitudes are changing. Access is improving. The discipline of health psychology and psychosocial oncology is producing more research every year to support these ideas and how these interventions can be effective. With that research under our belt, it's easier to advocate for these resources, whether they be from hospital systems or from the government. There has been progress there.

What unmet needs still exist within this space?

There is still a big gap between availability of mental health care and the need for mental health care. It is a problem that is endemic everywhere, throughout through all our systems. We are on this path to better integration of mental health care from start to finish with the patient. There are examples of places where that is happening, but more often than not, behavioral health care is not fully integrated [although it] needs to be. The 2 biggest impediments to that are having the [proper] staff, but also getting the general patient population to acknowledge that mental health care is a part of cancer health care.

Although we have made great progress within the field of oncology in appreciating the need for mental health care, the patient side hasn't necessarily made that progress. [Some] patients do not want to be labeled as “crazy” or needing a psychologist. [Often], they see mental health care as something that occurs separate from physical health care. [They might think]: “This is a type of treatment for a different type of person, that is not me.”

Therefore, there is a stigma there to mental health care from the patient. That puts up a barrier for the patient's willingness to access that. That is a very important part of this conversation: using all resources to normalize the need for mental health care for all people. [Getting the message across that] talking to a therapist while you have cancer does not mean that you are crazy; it does not mean that you're not coping well or that you are doing a bad job of managing your cancer and everything that's going on around you. Distress related to cancer is normal, it is part of the process, and [it is helpful to] work with a person largely in a coaching capacity to talk about how you can best use your own motivations, reasons, and own resources to better understand how emotions and thoughts and behaviors all connect and can be managed.

Breaking down that stigma is the biggest piece of this and the biggest gap we need to change.

In your opinion, do patients often require different therapies or different approaches, depending on if they're in the inpatient or outpatient setting?

Usually, when someone is in the inpatient setting […] that can be a good amount of time to introduce yourself to somebody, develop a rapport, and start working on some of these skills. However, you may only meet with a psychologist in the hospital a handful of times. If you're living physically away from the hospital and our elder, you're probably not going to come in to see them for physical appointment. However, through telehealth, it has made it easier to follow up with people where there's a geographical barrier. Generally, inpatient therapy is more short term, supportive, and focused on tolerating distress.

On the outpatient side, if you're doing CBT, you might have anywhere between 10 or 20 sessions occurring once a week for 1 hour, where you gradually start learning to build these skills. Then, you transition from a place where the therapist is giving you a lot of information, support, and training to more where you're becoming more independent, and the therapist is doing more coaching or support along the way, and you need the therapists less and less.

The focus is different. The timeframe is different, but we can use CBT and motivational interviewing principles in both contexts.

Is there anything else that you would like to discuss?

[A lot] goes back to that idea of normalization and stigma. If we can make psychologists and behavioral health professionals’ part of the entire process from start to finish, that is going to help in breaking down [that stigma]. [We need] everybody as part of the oncology team to reinforce this idea that distress is normal and there are ways of coping with it effectively.

An expert with Allegheny Health Network discusses the value of behavioral therapy and how access and stigma often play a role in preventing patients from receiving this form of care.

Behavioral Health Care Gaps Remain in Oncology Care

A proactive nurse-led monitoring program helped patients with metastatic melanoma receiving ipilimumab (Yervoy) successfully maintain low rates of severe toxicity, although disease-related hospitalization rates remained high, according to findings published in 

Among 67 patients receiving active treatment with the agent, there were 44 incidents (66%) of treatment-related adverse events (AEs). Overall, only 4 (6%) cases of grade 4 AEs and 3 (4%) grade 4 AEs were reported. However, 20 patients (30%) were admitted to the emergency department and 31 patients (46%) were hospitalized during the study follow-up. Of these patients, 9% of ER visits and 6% of hospitalizations were linked to drug toxicity and the rest were the result of disease progression.

“The key to management is early recognition and treatment,” Ines B. Menjak, MD, MSc,Division of Medical Oncology, University of Toronto, and coinvestigators explained in the study. “Guidelines have been published on management of immune-related toxicity; however, the organization and delivery of multidisciplinary care is dependent on local healthcare providers. No prospective trials have been done to guide the management of irAEs. At many centers, patients return for clinical assessment before each cycle of treatment, and there is currently no standard on how to best monitor patients in between clinic visits.”

The single-center study therefore assessed the reports from 67 patients receiving ipilimumab; the mean age was 61 years. While all patients received ipilimumab, 33 patients (49%) received 4 doses and 17 patients (25%) experienced a dose delay. In addition, the mean number of AEs reported per patient was 11 (range, 8-17).

Utilizing electronic medical records from Sunnybrook Health Sciences and the Global Melanoma Research Network, researchers conducted a retrospective chart review. Enrolled participants were treated between 2012 and 2017 with single-agent ipilimumab at a dosage of 3 mg/kg every 3 weeks and were scheduled to receive 4 doses each. AE reports were collected from clinic visits, records indicating ER visits, and hospitalizations. Researchers looked at clinical notes to determine if the underlying causes of AEs were definitely, probably, possibly, unlikely to be, or unrelated to agent administration. Hospitalization and ER visit data were collected 3 months post-ipilimumab discontinuation.

Before treatment began, each patient received a 15-minute one-on-one nurse led education session regarding ipilimumab and potential AEs, offering clear guidance on when to call the nursing line for assistance. These conversations were guided by The Cancer Care Ontario Ipilimumab Patient Information Sheet used by the institution.

Once treatment began, RNs phone patients on a weekly basis throughout each administration and for 8 additional weeks following treatment completion. To ensure maximum efficiency, nurses did not call patients on the same week they saw their physician in clinic, unless explicitly instructed to do so by the physician. Each phone call lasted between 5 to 20 minutes, during which time the nurse queried about symptoms, offered symptom-management advice over the phone, and contacted physicians if they believed it necessary. All participating RNs were oncology nurses specializing in melanoma who had received prior immunotherapy toxicity training. The mean number of received phone calls was 8.

Each patients experienced at least 1 AE, while the median of any grade all-cause AEs was 11 (range: 8-17). RNs successfully identified most (63%) AEs via a monitoring phone call, while a clinic visit identified approximately 29% of AEs, and a patient-initiated call in was responsible for 8% of identified AEs.

Nearly 70% (69.8%) of reported AEs were grade 1, while 26% were grade 2, 3.5% grade 3, and 0.2% were grade 4. Grade 3 treatment-related AEs included diarrhea or colitis, fatigue, and flare of rheumatoid arthritis. Thirty-four patients were prescribed an analgesic following their RN phone call.

Out of the 67 patients assess throughout the study follow-up period, 31 (46%) required hospitalizations. The most common causes for ED visits were diarrhea, pain, ulcer, and rash.

“Using this model of care, 63% of toxicity was identified over the phone before clinic visits, allowing for earlier intervention than standard practice,” the study authors wrote. “Nurses communicated with physicians to facilitate provision of appropriate symptom management, including prescriptions for corticosteroids and other agents in a timely manner. Nursing workload involved weekly calls with a median in our cohort of eight weekly calls per patient (on weeks that patients were not seen in clinic by their oncologist), and additional calls were minimal. This model of care is consistent with the current expansion of virtual health care because of the COVID-19 pandemic as it provides timely virtual access to healthcare providers.”

“This study provides single-center real-world evidence of toxicity, hospitalizations, and ER visits, as well as nursing utilization for a proactive phone-based symptom monitoring and intervention,” they concluded.

Since the study intervention, the institution has expanded their program to include patients receiving ipilimumab in combination with nivolumab (Opdivo), since the toxicity associated with the combine regimen is notably higher than with single-agent ipilimumab. The researchers hope to soon expand efforts to include other tumor types and immunotherapy combinations, including chemotherapy plus immunotherapy for patients with lung cancer, in order to address relevant toxicity.

Menjak IB, Elias ES, Jain S, et al. Evaluation of a multidisciplinary immunotherapy toxicity monitoring program for patients receiving ipilimumab for metastatic melanoma. 

. 2022:17(11)e1631-e1638. doi:10.1200/OP.20.00845.

Weekly phone calls from RNs helped reduce the number of severe adverse events experienced by patients receiving ipilimumab for metastatic melanoma. 

Nurse-Led Program Demonstrates Initial Success in Reducing Severe Immune-Related Toxicity in Melanoma

Unfortunately, there is great variability between the types of behavioral support that patients with cancer receive, according to Matt Iwaniec, PsyD.

Nevertheless, patients who can access programs with fully integrated behavioral programs benefit from the lack of barriers and ease of access, the licensed clinical health psychologist explained.

 Iwaniec, who works with the stem cell transplant and CAR-T therapy program at Allegheny Health Network, explained how the behavioral health services function at his own institution compared with institutions which involve a third-party therapy team.

“The idea is for behavioral health [to] be fully integrated, meaning you get a diagnosis, you are introduced to the mental health professional who's already working in the clinic—[someone who] has an established relationship with the other people working in that clinic,” Iwaniec explained. “Then you can orient them to what behavioral health care looks like, what services are available to them, how they access those services, how often they would see you, what you would be working on, etc.”

“What is more typical [in traditional institutions] is that people will see an oncologist and they might be screened for some type of emotional distress. Maybe they have symptoms of anxiety or have symptoms of depression, and [therefore] a nurse or provider will refer them to a behavioral health provider that's outside of the clinic— somebody else in the community that they might have sort of a somewhat distant relationship with. They're not working directly together, but they're aware that they're out there and they try to funnel patients into that location.”

“[But] the patient is responsible for contacting that person, making the appointment, getting themselves [to the appointment],” he added. “They are [not] getting introduced to that person for some time. That distance really creates a barrier to the patient receiving that that care, because there's a physical distance. There's a temporal distance between the time they get the diagnosis, and they see the provider. And there may be a lot of unanswered questions: “Will insurance cover it? How do I get there? How do I arrange transportation?”

A licensed clinical health psychologist with Allegheny Health Network discusses fully integrated behavioral health programs and how their design alleviates potential barriers to care that patients may experience. 

Integrated Behavioral Health Vs Standard Practice: What’s The Difference?

In 2018, the US surgeon general issued an advisory calling for immediate action against the epidemic of youth electronic e-Cigarette use.

For the past 7 years, e-cigarettes have been the most commonly used tobacco product among US youth

 with an estimated 1 in 5 high school students and 1 in 20 middle school students using them.

Nurses are on the front lines and are a direct touch point in the effort to curb e-cigarette use among children and teenagers, according to Joelle Fathi, DNP, RN, ARNP, CTTS, FAAN, chief healthcare delivery officer at the GO2 Foundation for Lung Cancer and deputy chair of the Tobacco Control and Smoking Cessation Committee at the International Association for the Study of Lung Cancer. 

“Nurses [belong to] the No. 1 most trusted profession. If more nurses understand how these products hijack the brain and neurohormones, they can use this information to educate children and have [repeated] conversations about the harms before they are ever exposed,” Fathi said. 

Conventional or combustible tobacco includes tobacco products designed to be burned and smoked, such as cigars or cigarettes. In contrast, e-cigarettes work by heating the tobacco product. 

The FDA defines these products as electronic nicotine delivery systems (ENDS), which include vapes, vaporizers, vape pens, hookah pens, e-cigarettes, and e-pipes.

To best educate their patients, it is important that all nurses understand the mechanism of addiction for nicotine. 

“When someone inhales vapors from ENDS, those gases go into the depths of the lungs; they permeate across the very fine lining of the lung and into the arterial bloodstream,” Fathi noted. “From the time of inhalation it takes only about 7 seconds for any substance in that tobacco to reach the brain and other organs via the arterial blood stream. 

“There are other things that cause these surges, but nothing can touch the surge that nicotine causes. It takes only as few as 3 repetitive exposures to develop nicotine dependence,” she said. “When people use nicotine, even for a short duration, their neurocircuitry never goes back to normal.”

The good news, according to Mary Rezk-Hanna, PhD, NP, FAHA, an assistant professor at UCLA School of Nursing, is that there has been a clear reduction in the use of combustible cigarettes among adolescents. Unfortunately, the use of e-cigarettes and other alternative tobacco and nicotine products is offsetting that decline. Data show that from 2011 to 2018, the use of e-cigarettes increased among high school students from 1.5% in 2011 to 20.8% in 2018.

Nurses can raise awareness among adolescents about the amount of nicotine in e-cigarettes. For example, 1 combustible cigarette contains about 1 mg of nicotine. Smoking a pack of 20 cigarettes a day would equal 20 mg of nicotine. In comparison, one 3% JUULpod contains 35 mg of nicotine per mL, or about 23 mg of total nicotine at the time of manufacture. The 5% JUULpod contains 40 mg of nicotine.

e-Cigarettes have not been around long enough to fully understand the long-term associated health risks. However, as of 2020, more than 2800 hospitalized cases or deaths from e-cigarette or vaping product use– associated lung injury (EVALI) had been reported to the Centers for Disease Control and Prevention (CDC).

 Symptoms of EVALI include respiratory symptoms, gastrointestinal symptoms, and constitutional symptoms such as fever, chills, and weight loss. 

“Nurses have a critical role in controlling the smoking epidemic,” Rezk-Hanna said. 

Research findings have indicated that compared with smokers who receive usual care, smokers who receive assistance from a nurse have a 29% greater probability of successfully quitting for 5 or more months. This emphasizes the importance of nurses in efforts to curb tobacco use.

According to Rezk-Hanna, the 5 A’s framework for promoting smoking cessation (ask, advise, assess, assist, and arrange) is highly effective and nurses should be encouraged to use it with their patients. This means that nurses should identify tobacco use status for every patient at every visit (ask). They should urge tobacco cessation (advise) and determine whether the user is willing to attempt to quit (assess). For those who are willing, nurses should provide counseling and pharmacotherapy to help (assist), and schedule a follow-up (arrange).

“Assisting patients to achieve permanent [smoking] cessation is one of the most important services we can offer them to protect their health now and in the future,” Rezk-Hanna said. 

Some excellent cessation resources are available, including 1-800-QUIT-NOW, a national portal to a network of state quit lines. The Truth Initiative has launched an e-cigarette quit program to address the increase in youth vaping. To access the new program, users must text “DITCHJUUL” to 88709 to enroll. The American Lung Association’s Not On Tobacco is a voluntary quit program for young people aged 14 to 19. 

Treatment combined with behavioral counseling is the best way to help patients quit, Fathi said. Nurses have to be familiar with and know how to access local behavioral counseling resources and pharmaceutical treatments. For example, Yale Tobacco Center of Regulatory Science has launched a vaping cessation program for young people aged 14 to 19 years in Connecticut. 

“The biggest bang for our buck will always be to prevent youth from ever picking these products up,” Fathi said. “There is clear science that demonstrates that 90% of people who have used tobacco lifelong started before the age of 18.” “If we can change that…smoking will be obliterated.” 

1. Surgeon General’s advisory on e-cigarette use among youth. CDC. December 2018. Updated October 21, 2021. Accessed January 4, 2022. 

2. E-cigarette use among youth and young adults: a report of the Surgeon General. US Department of Health and Human Services. 2016. Accessed January 4, 2022. 

3. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: increase in use of electronic cigarettes and any tobacco product among middle and high school students – United States, 2011-2018. 

. 2018;67(45):1276-1277. doi:10.15585/mmwr.mm6745a5

4. Vaporizers, e-cigarettes, and other electronic nicotine delivery systems (ENDS). US Food and Drug Administration. Updated September 17, 2020. Accessed January 6, 2022. 

5. What is the size of a JUULPOD? JUUL. June 15, 2020. Accessed January 6, 2022. 

6. Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. CDC. Updated August 3, 2021. Accessed January 6, 2022. 

7. Rice VH, Hartmann-Boyce J, Stead LF. Nursing interventions for smoking cessation. 

 2013;(8):CD001188. doi:10.1002/14651858.CD001188.pub4

8. Five major steps to intervention (the “5 A’s”). Agency for Healthcare Research and Quality. December 2012. Accessed January 6, 2022. 

Awareness of the e-cigarette epidemic among youth could help
drive primary prevention.

The Rise of e-Cigarettes— What Nurses Should Know

As of February 2022, 37 states along with the District of Columbia have legalized medical cannabis, and 19 states plus the District of Columbia have legalized adult-use cannabis.

Unsurprisingly, the use of cannabis in patients with cancer appears to be increasing as more and more states are adopting cannabis legislation, both for medical and adult use.

Moreover, in addition to increased cannabis legalization, there has been an explosion of cannabidiol and other non-impairing cannabinoids that hit the market—thanks to the 2018 Farm Bill, which descheduled hemp.

With nearly two-thirds of the states allowing for medical cannabis use and the legalization of hemp, accessing cannabinoids has become much easier, especially for patients with cancer, which is a qualifying condition in almost every state. The increased access to cannabinoids has led to patients’ curiosity. Many of these patients are seeking symptom relief with cannabis and are turning to their oncology care team for further guidance.

Yet, many oncology professionals have had little to no education on cannabis.

 in 2018, 70% of medical oncologists felt unequipped to make clinical cannabis recommendations, and 46% of oncologists are recommending cannabis for symptom relief even though they have had no formal training.

 Additionally, an estimated 20% to 40% of patients with cancer are consuming some form of cannabis either during or after treatment—and that number may be underreported in states where cannabis is not legal.

Uncertainty exists among the different types of cannabis and whether clinical evidence supports cannabis use in certain medical conditions. Research is limited due to the federal designation of cannabis as a Schedule I drug.

Despite this restriction, there is sufficient evidence in some areas to demonstrate that cannabinoids may have a therapeutic effect. In 2017, the National Academy of Sciences, Engineering, and Medicine released The Health Effects of Cannabis and Cannabinoids report, which followed a review of more than 10,000 peer-reviewed journals. The authors concluded the following

1. Conclusive evidence suggests that cannabis or cannabinoids are effective at treating chronic pain in adults with chemotherapy-induced nausea and vomiting.

2. Moderate evidence suggests that cannabis or cannabinoids are effective at improving short-term sleep disturbances, and limited evidence suggests effectiveness at improving appetite and decreasing weight loss. 

3. There is insufficient evidence to demonstrate whether cannabis or cannabinoids are effective or ineffective in treating patients with gliomas or cancer-associated anorexia-cachexia. 

Despite the comprehensive review of the literature, generalized anxiety disorder and chemotherapy-induced peripheral neuropathy were not addressed. However, the report highlighted the need for more clinical research to better understand the therapeutic effects of cannabinoids in certain diseases.

Even though limited data support the use of cannabis as a first-line treatment in cancer-related symptoms, many patients are using it to relieve anxiety, pain, nausea, vomiting, and insomnia. In a recent Cancer study, 42% of 612 patients with breast cancer reported using cannabis for symptom relief.5 Seventy-eight percent used it to help with pain, 70% for sleep, 57% for anxiety, and 46% for nausea and vomiting relief.

Data also found that 39% of participants discussed their cannabis use with their physicians and that when they did, it was initiated by the patient 76% of the time. Moreover, only 4% of respondents listed their physician as the most helpful source of information on cannabis, instead listing the internet (22%), family members (18%), and dispensary staff (12%) as a more helpful source of information. This trend is concerning, considering that the internet is not always an accurate or reliable source of information and that dispensary staff often have no medical background and little cannabis education.

Oncology professionals can start to address patient questions and concerns by educating themselves on the endocannabinoid system, cannabinoids, routes of administration, dosages, potential drug-drug interactions, adverse effects, and common cancer-related uses and considerations.

Unfortunately, this information is not widely taught in medical or nursing schools, and without standardized cannabis education, clinicians are self-selecting sources to decrease their knowledge gap. Foundational knowledge of key concepts can allow oncology professionals to better guide patients to safe and effective use.

Discovery of the first cannabinoid receptor in 1988 led to detection of the endocannabinoid system (ECS). The ECS, of which the main function is to maintain homeostasis, is a molecular signaling system that consists of 2 cannabinoid receptors (most commonly CB1 and CB2), ligands, and enzymes that normalize sleep, pain perception, memory, mood, and appetite. These receptors can be stimulated by human endogenous cannabinoids as well as plant-derived cannabinoids (phytocannabinoids) and synthetic cannabinoids.

CB1 and CB2 are known as G protein–coupled receptors, and CB1 receptors are found predominantly in the adrenal glands, heart, kidneys, prostate, pancreas, colon, liver, central and peripheral nervous systems, lungs, testes, and ovaries. Upon CB1 receptor activation, the CB1 receptors assist in relief from depression, anxiety and stress, pain and inflammation, neurodegenerative disorders, posttraumatic stress, and multiple sclerosis–related symptoms.

CB2 receptors are also detected in the brain and peripheral nervous systems. However, these are mostly contained in the peripheral immune cells. These receptors are found in the brainstem neurons, lungs, microglia, and uterus. Upon activation, CB2 receptors are known to reduce inflammation and treat mental health disorders and neurologic diseases such as Alzheimer, Parkinson, Huntington, and multiple sclerosis.

Cannabinoids are defined as chemical compounds, which can be plant-derived (phytocannabinoids), synthetic, or endogenous, with the ability to influence the cannabinoid receptors while promoting neurotransmitter release. D-9 tetrahydrocannabinol (THC) and cannabidiol (CBD) are the 2 most commonly known cannabinoids, the first of which is primarily responsible for the euphoric effects of cannabis. Behavior, consciousness, mood, and perception are all altered by Δ-9 THC, which binds to CB1 receptors in the brain and causes a change to the function of the binding cell. Studies have suggested efficacy when using Δ-9 THC to treat the following conditions

CBD is typically the second most abundant cannabinoid in cannabis. It is psychoactive but not in the same manner as THC. It can alter mood, perception, and decrease anxiety. Studies have suggested that CBD can also treat patients with the following conditions

THC and CBD can be found in the cannabis plant along with more than 100 other cannabinoids and can often be purchased through licensed dispensaries in legal states or through hemp retailers (online and in store). Phytocannabinoids are not standardized, and states can set their own limits on potency and testing. FDA pharmaceutical-grade THC is available via dronabinol, which is synthetic and has been approved as an antiemetic and appetite stimulant. Cannabidiol (Epidiolex) is a medication that is derived from the cannabis plant and approved by the FDA as an anticonvulsant. In states where cannabis is legal for medical or adult use, patients can explore cannabinoids for a variety of health conditions without FDA approval.

Cannabis products offer various routes of administration, including topical, transdermal, inhalation, sublingual, and ingestion. Understanding the onset and duration of action can be helpful in determining which route will effectively treat patient symptoms. Unfortunately, products’ availability to patients depends on an individual state’s cannabis laws, and many state cannabis programs severely limit the product and formulary options.

Topical administration can provide localized relief within 15 minutes and often has little to no adverse effects (AEs). Upon activation, CB1 receptors on the skin assist in redness and inflammation reduction linked with conditions such as atopic and contact dermatitis and psoriasis. Evidence also suggests that topical cannabis can reduce arthritis-related pain and inflammation. There is little risk involved with this administration method.

Transdermal cannabis products—which are most commonly patches—are intended to penetrate the skin and reach the bloodstream and can provide between 6 and 12 hours of relief while avoiding first-pass metabolism. Transdermal products may be the optimal administration choice in patients whom drug interactions or medication adherence is a concern.

Inhalation provides relief quickly by reaching the bloodstream within minutes; this method is also found to be the most predictable while having the most control. It also provides a benefit for those who are unable to ingest other forms of medications. Chronic use has been associated with bronchitis and airway inflammation, so the benefit must outweigh the risk. Additionally, most indications for inhalation are short term.

Ingesting cannabis is a go-to choice for patients who suffer from chronic pain, inflammation, nausea, and insomnia because it can provide more durable and dependable relief. However, it does have variability in onset of action and is dependent on a patient’s metabolism, genetics, gender, and food intake. Taking these factors into consideration, the onset of action can range from 30 minutes to 2 hours or more. That being said, the effects of ingesting cannabis can last for at least 5 hours. Because of this factor, patients can overconsume and experience AEs, such as tachycardia, paranoia, hypotension, vomiting, and hallucinations. AEs associated with cannabis use are often from ingestible products. The use of the “go low and slow” method can help avoid some unwanted AEs associated with cannabis overconsumption.

Although drug interactions with cannabis are rarely hazardous, there is still potential for interactions to occur, especially with ingested cannabinoids. When taken orally, cannabinoids are metabolized by the cytochrome P450 (CYP) family of enzymes. THC is often metabolized by the CYP2C9, CYP2C19, and CYP3A4 enzymes, which convert THC into 11-hydroxy-THC. CBD, however, is commonly metabolized by the CYP2C19 and CYP3A4 enzymes, which convert CBD into 7-hydroxy-cannabidiol.

 Because most medications are metabolized by CYP3A4, CBD and THC can inhibit or induce other medications metabolized through that same

enzyme. Warfarin, among other medications, can inhibit or induce THC and CBD, which increases or decreases cannabinoid plasma levels.

 Cannabis should be used with caution with other central nervous system depressants, including alcohol, since it can generate sedative effects.

Cannabis dosing remains one of the most challenging components of providing care. Very few clinical trials have established dosing protocols with cannabinoids for specific conditions. As it stands, most dosing protocols have been developed from realworld evidence rather than evidence-based trials. The go-low-and-slow method is most applicable with cannabis. Because cannabinoids can have biphasic effects, a low dose is often sufficient for symptom relief.

With cannabis accessibility on the rise, many patients with cancer will be seeking guidance on the safe and effective use for symptom management. As cannabis research evolves and the industry matures, oncology professionals can look to cannabinoids as a potential supportive medicine. With proper guidance, cannabis can have a high safety profile with adverse effects that are generally well tolerated when administered at low doses. Patients are using it. Therefore, oncology professionals must be ready to meet the needs of their patients.

State Medical Marijuana Laws. National Conference of State Legislatures. Updated February 3, 2022. Accessed February 4, 2022. https://www.ncsl.org/research/health/ state-medical-marijuana-laws.aspx

Braun IM, Wright A, Peteet J, et al. Medical oncologists’ beliefs, practices, and knowledge regarding marijuana used therapeutically: a nationally representative survey study. 

. 2018;36(19):1957-1962. doi:10.1200/JCO.2017.76.1221

Worster B, Handley N, Ashare R, Meghani SH. What do oncology providers need to know about cannabis use in patients with cancer? ASCO Daily News. September 2, 2021. Accessed October 25, 2021. https://dailynews.ascopubs.org/do/10.1200/ ADN.21.200700/full

With nearly two-thirds of the states allowing for medical cannabis use and the legalization of hemp, accessing cannabinoids has become much easier— especially for patients with cancer.

Medical Cannabis 101: What Oncology Nurses Need to Know 

Janelle Wagner, RN, OCN, has been an oncology nurse for almost 20 years and an oncology nurse navigator for 5 years.

®, Wagner, Senior Manager of Patient Navigation Program for Community Sites, Seattle Cancer Alliance, discusses some of the more difficult components associated with the role. Among them, she mentions the struggle to define clear boundaries, navigate the health care system without trying to fix it, and understanding that patients are now a part of your team.

“Setting boundaries [is difficult],” Wagner explained. “Oncology nurse navigation is a newer field, and there are many different opinions on what the job entails. Being able to set those boundaries and kind of sticking with your standard work to be able to best serve the patient [is crucial]. The challenge is understanding [that] our health care system is so complex, and that you really need to be the point person for that patient to navigate through that system [rather than] trying to fix the system.”

She added that, “If somebody is going to go into this field, they need [to] make sure that they have good leadership, and good pathways for the position. It is really questioning [the following]: what does standard work look like? Who is my team? When you are navigating a patient through the whole continuum of care, it could be across many different organizations. [You need to understand] who that team is and how to utilize [your] skills to help the patient go through the system.”

Janelle Wagner, RN, OCN, Senior Manager of Patient Navigation Program for Community Sites, highlights some challenges commonly associated with nurse navigation, and how nurses can overcome them. 

Setting Boundaries Can Be a Challenge for Nurse Navigators

Oncology nurse navigators, which are also referred to as “ONNs,” are professional registered nurses with oncology-specific clinical knowledge. Professionals in this role help patients navigate the various steps of their cancer care journey by offering education and resources to help promote informed decision making and access to quality health and psychosocial care. They assist patients, families, and caregivers circumvent barriers in the health care system.

Janelle Wagner, RN, OCN, Senior Manager of Patient Navigation Program for Community Sites, Seattle Cancer Care Alliance, recently met with 

Janelle Wagner, RN, OCN, Senior Manager of Patient Navigation Program for Community Sites, discusses the challenges and rewards of nurse navigation in oncology.  

Nurse Navigation