An ongoing four-year study based out of the University of Wisconsin-Madison Carbona Cancer Center seeks to determine the best way to improve colorectal cancer screening rates in rural areas.

“Our goal is to learn from the clinics that are doing it correctly and doing well and see if we can take their strategies and help disseminate them to lower-performing health care settings that have similar access to resources, similar patient populations,” said lead researcher Dr. Jennifer Weiss, a gastroenterologist at the UW Carbone Cancer Center and associate professor at the University of Wisconsin School of Medicine and Public Health.



Researchers will survey, tour and interview at more than 200 rural primary care clinics in the upper Midwest. They’ll use early data showing which clinics are high performing (having successfully screened 80% or more eligible patients) to then identify common best practices at those clinics. They also plan to examine the potential causes or barriers leading to lower screening rates at certain clinics.

Weiss said that during her time as a gastroenterologist, she has seen a number of cases where a patient received a colorectal cancer diagnosis that could have been prevented with appropriate or timely screening.

“I think one of the things that people don't understand is we can actually prevent colorectal cancer,” she said. “Most people talk about breast cancer screening – with breast cancer screening, we're trying to identify a breast cancer at the earliest stage possible. With colorectal cancer screening, we can actually identify the precancerous lesion, which is a colon polyp, and take it out before it turns into a cancer.”

Weiss became more interested in health care system- and patient-level interventions to address screening issues. She and fellow researchers began their work in 2008, studying whether multilevel interventions at a large academic health center in a midsize city would help increase screening rates.

“We were able to increase our screening rates over 20% so that we’ve maintained over 80% screening rates for the last five years” Weiss said. “But I started to realize that what we were doing here at an academic health center might not be immediately applicable or transferable to other types of health care settings.”

As Wisconsin has a large rural community, Weiss set out to find a way to translate the lessons they’d learned from the 2008 study to rural clinics. The research is funded by a $1.2 million grant from the American Cancer Society in partnership with the Wisconsin Collaborative for Healthcare Quality.

Though the researchers won’t know for sure until the study is complete, Weiss hypothesizes that one reason that certain rural clinics have not been able to achieve adequate colorectal cancer screening rates may be due to lack of regular access to care.

“Or they access care only for urgent or immediate concerns and are not really doing that yearly preventive exam where there’s time to sit down and talk about the prevention strategies that they can do to help with their health care,” Weiss said.

She added that in many places, regardless of being a rural or urban setting, there’s a difference in how colorectal cancer screening is portrayed and talked about by primary care providers in terms of what tests are available.

“In the United States, we talk a lot about colonoscopy,” said Weiss. “And as a gastroenterologist, I definitely agree colonoscopy is a great colon cancer screening test. But there's also data to show that offering multiple types of screening tests is one way to increase colon cancer screening rates.”

Patients in rural settings may have decreased access to providers who perform colonoscopies due to distance, she explained. However, their providers could explain or offer another reasonable alternative, such as an at-home stool test. This is also a more affordable option than a colonoscopy, which is significant considering that a lack of insurance coverage may be another reason preventing these patients from getting screened.

“I think there's also just issues potentially about this sensitive topic,” said Weiss. “So ideas about talking about a colonoscopy with your provider or with family members may not be felt to be appropriate, or people might have a bit of a stigma about colorectal cancer. Especially if their doctors are really only talking about colonoscopies. So, I think that the discussion needs to be had, I think people really need to talk about their family history. They need to find out who else in their family has had colon cancer, because that increases their potential risk.”

This article was originally published on Cure® as “

New Initiative Explores How to Increase CRC Screening Rates in Rural Areas

Articles

Novel research at University of Washington aims to improve the rate of colorectal cancer screenings in rural America. 

New Strategies Aim to Expand Preventative CRC Screenings in Rural America

Presented findings from the 36th Annual European Association of Urology (EAU) Congress showed that urologic care experienced a significant decline throughout the peak of the COVID-19 pandemic. Despite varying stay-at-home order mandates, all demographic groups and practice settings in the United States reported similar findings.

Notably, declines of more than 40% were observed among outpatient visits from March 2020 to April 2020. Although outpatient visits recovered through May 2020 and early June 2020, they began to fall again in July 2020 in the overall population.

“This study provides timely, real-world evidence on the magnitude of decline in the provision of urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urologic health services by sociodemographic strata and specific diagnoses,” Daniel J. Lee, MD, MS, an assistant professor of urologic oncology in the Department of Surgery at the Perelman School of Medicine at the University of Pennsylvania, and co-authors wrote.

Non-urgent visits, including visits for microscopic hematuria, overactive bladder, elevated prostate-specific antigen, erectile dysfunction, and benign prostatic hyperplasia, also declined, as did procedure visits.

Non-urgent visits declined by 39% to 47% from March 2020 to April 2020, whereas visits for urgent diagnoses declined by 29% to 43%. Surgical procedures for non-urgent conditions declined by 37% to 53% compared with surgical procedures for potentially urgent matters, which declined by 13% to 21% during the evaluated time period.

The COVID-19 pandemic affected facets of health care access and delivery, including hospital admissions and outpatient care for certain conditions, throughout the United States, wrote Lee and co-authors. However, the significance of the pandemic with regard to specialty care had not been fully realized, which provided the clinical rationale to conduct the analysis.

The specialty-wide, community-based cohort study evaluated trends in outpatient urologic care visits, as well as procedural volume from February 2020 to July 2020. The study utilized the American Urological Association Quality (AQUA) Registry, which automatically extracts patient data from electronic health records.

AQUA collects data from 157 urology practices, which comprise 3,165 providers. Notably, these providers account for approximately one-fourth of all urologists in the United States, wrote Lee and co-authors. The practices are spread across 48 states and territories in the United States.

The trends were evaluated based on patient, practice, and local or regional demographic and pandemic response features.

Primary outcomes included mean visit volume and procedure volume-per-week, which were compared with the respective weeks in 2019.

Overall, 2,750,001 patients were included in the cohort, which comprised 8,953,832 outpatient visits and 1,570,161 procedures.

The decrease in visits was smaller among African American and Hispanic patients compared with Asian and Caucasian patients; however, African American and Hispanic patients experienced a slower recovery in visits to baseline.

Patients insured by Medicare, most of whom were over the age of 65, observed the steepest reduction in visits at 50%. Additionally, 84.4% of patients insured by Medicaid, most of whom were low-income patients, did not recover to the baseline number of weekly visits before the COVID-19 pandemic.

Finally, among practices located in areas with lower median incomes, higher poverty levels, and lower urologist-to-population rations experienced smaller decreases in outpatient visits.

Lee DJ, Shelton JB, Brendel P, et al. Impact of the COVID-19 pandemic on urologic care delivery in the United States. Presented at: 36th Annual EAU Congress; July 8-12, 2021; Virtual. Abstract P0183.

This article was originally published on OncLive as 

“Urologic Care Rates Decline Across US Demographics During Height of COVID-19 Pandemic”

The impact of the pandemic in regard to specialty care remains to be fully realized. 

Urologic Care Rates Decrease Throughout Climax of COVID-19 Pandemic   

The World Health Organization estimates that 30% to 50% of cancer cases are preventable, and usually people think this means modifying health behaviors such as not smoking tobacco, maintaining a healthy body weight, getting regular physical activity, limiting alcohol, and eating a healthily.

But there are additional ways to prevent cancer, including risk-reducing surgical procedures, screening, and early detection that remove precancerous lesions before they develop into cancer, or medical interventions such as chemoprevention.

As an oncology nurse working with people who have been diagnosed with cancer, you might not feel that cancer prevention is part of your practice. After all, you might be hanging their chemotherapy, managing their adverse events from radiation therapy, or helping them prepare for their surgical resection. But an oncology nurse can play an incredibly important role in cancer prevention as the patient moves across the cancer continuum.

For example, a woman I worked with as a breast oncology nurse navigator was newly diagnosed and developing a surgical plan for a lumpectomy. She confided that she didn’t understand why this was happening to her since no women had ever been diagnosed with cancer in her family. She had recently learned a few males in her family had been diagnosed with metastatic prostate cancer but hadn’t thought to share this with the oncology team. As an oncology nurse, I understood that metastatic prostate cancer is part of the National Comprehensive Cancer Network criteria for genetic testing,

 and I coordinated with her health care provider a referral for genetic counseling. Her genetic testing came back positive for the BRCA2 pathogenic variant and she felt very overwhelmed when her surgical oncologist recommended bilateral mastectomies.

We discussed the importance of preventing breast cancer in the contralateral breast and connected her to social support services. She did decide to have the bilateral mastectomies.

Later when she was completing her treatment and entering the survivorship phase, we discussed her health care provider’s recommendation for a risk-reducing salpingo-oophorectomy since she had an increased risk of ovarian cancer with the BRCA2 pathogenic variant. In the survivorship care plan, we discussed how colonoscopy and the Pap test are cancer screening tests that can remove precancerous lesions before they develop into cancer.

We also addressed cancer prevention for her family members by coordinating appointments for them with the genetic counselor.

Oncology nurses can talk to their patients about cancer prevention in the treatment phase as well as the survivorship phase. As trusted members of the health team, nurses are in a unique role to educate patients and their family members on cancer prevention and risk reduction strategies.

 World Health Organization. Accessed December 22, 2020. 

https://www.who.int/activities/preventing-cancer

2. National Cancer Institute. Cancer prevention overview (PDQ)-Health professional version. October 7, 2020. Accessed December 20, 2020. 

https://www.cancer.gov/about-cancer/causes-prevention/hp-prevention-overview-pd

3. National Comprehensive Cancer Network. Genetic/familial high-risk assessment: Breast, ovarian, and pancreatic (version 2.2021)

https://www.nccn.org/professionals/physician_gls/pdf/genetics_bop.pdf

4. Cancer screening tests. National Cancer Institute. January 16, 2019. Accessed December 26, 2020. https://www.cancer.gov/about-cancer/screening/screening-tests

Oncology nurses can play a key role in the prevention of certain cancers.

Oncology Nurses Can Help Prevent the Preventable

Monumental strides in cancer treatment have been made in recent years, though there is still far more work to be done when it comes to cancer screening and diagnostic procedures, according to the American Cancer Society’s “Blueprint for cancer research: critical gaps and opportunities.”

“With only 4 of the 20 most common cancer types in the United States having a proven screening method to reduce mortality by identifying early-stage lesions, developing such tools for other high-incidence malignancies is urgently needed,” the 

The American Cancer Society worked with experts in the field to establish research opportunities that could lead to the development of better screening approaches in the future. They included:

Better understanding the molecular makeup of early-stage cancer and premalignant disease

Determining how the tumor microenvironment leads to the transition of premalignant to preinvasive to invasive disease

Creating better technologies for screening, early detection, and risk stratification

Improving the ways that biomarkers are analyzed and detected with a limited amount of fluid

Establishing how public health genomics can affect precision public health when it comes to cancer screening and earlier detection

Find ways to use artificial intelligence or machine learning and next-generation technologies (wearable devices, etc) to help in cancer screening and early detection.

Despite the existence of these major gaps, there have still been significant strides in diagnosing cancer and better understanding the disease biology.

For example, thanks to the advent of liquid biopsy, patients can undergo a blood test that provides vital information about circulating tumor cells, free tumor-derived DNA or RNA and cancer-derived exomes.

“A liquid biopsy offers many advantages over a traditional biopsy,” the report says. “It is minimally invasive, not generally limited in terms of sample accessibility and availability, and practical for repeat sampling, which could help clinicians during screening and surveillance as well as postdiagnosis to better understand the molecular changes occurring in a tumor over time.”

Additionally, every year researchers learn more about cancer biomarkers, and these discoveries continue to serve as the backbone for more personalized, efficacious cancer treatment.

Authors of the report hope that advances in genomics, proteomics, metabolomics, and lipidomics will further be used to develop better cancer screening as well as improve the cancer screening methods that are currently available — though those efforts have not yet been fruitful.

“With the advancement of metabolic profiling technologies, there have been notable efforts over the past decade to clinically exploit cancer-specific metabolism to aid in cancer detection,” the report says. “Thus far, translation and clinical utility have been somewhat disappointing.”

Ultimately, while 2020 did have scientific discoveries that will improve cancer treatment, there is still plenty of work to be done in 2021 and beyond.

Only 4 of the 20 most common cancers have a proven screening method.
 

Better Cancer Screening Is Needed: Hopes for 2021 and Beyond

Each month, we take a look back at the most popular 

 stories. Here are the top 5 stories from July 2020.

5. Dexamethasone Is Affordable and Promising in Treating COVID-19

As the coronavirus 2019 (COVID-19) pandemic continues, research efforts have revealed a potential weapon to add to the treatment arsenal against the virus, a drug that has historically played a crucial role in oncology treatment: the inexpensive, and widely accessible, 

4. Why Be an Oncology Nurse? A Patient Perspective 

Like many people, Jane Biehl, PhD, thought she knew what the field of oncology was all about — 

. Here, she details how her own experience as a patient with cancer has taught her all about the compassion and love found in oncology nurses.

3. Immunotherapy Does Not Increase Death Risk in Patients With COVID-19

According to new findings presented during the 2020 AACR Virtual Meeting: COVID-19 and Cancer, treatment with 

 did not increase the risk of mortality in patients with COVID-19 and cancer. Learn more in this recap.

2. Cancer Organizations Advocate for US to Remain in the World Health Organization

Leading cancer organizations and members of Congress recently wrote a letter to the White House advocating that the 

United States remain in the World Health Organization

 (WHO) after President Trump stated earlier this month that the US will withdraw from WHO.

1. Mental Health Treatment May Improve Cancer Outcomes

 may want to encourage patients to seek help, according to a recent study published in 

. Read more about these findings in this web exclusive.

Each month, we take a look back at the most popular Oncology Nursing News® stories. Here are the top 5 stories from July 2020.

Oncology Nursing News Top Stories: July 2020

 indicated that there has been a significant nationwide decrease in all cancer-related patient encounters as a result of the coronavirus disease 2019 (COVID-19) pandemic.

The findings also inherently suggest the possibility of a future increase in patients with later-stage cancer being seen, as well as an increased demand for cancer screening procedures due to delayed tests being rescheduled.

“These findings are truly striking, as modeling from the National Cancer Institute has predicted thousands of expected increases in cancer death as a result of deferred breast and colorectal screening alone,” Karen E. Knudsen, MBA, PhD, executive vice president of Oncology Services at Jefferson Health and enterprise director of the Sidney Kimmel Cancer Center (SKCC), said in a press release.

 “This report is a nationwide call to arms, underscoring the urgent need to resume cancer screening and early detection.”

Using the TriNetX platform, researchers analyzed 20 different healthcare institutions with relevant, up-to-date encounter data from January 1, 2019 through April 30, 2020 to create the COVID and Cancer Research Network (CCRN). They then compared the data from cohorts of patients with cancer pre-COVID (January 2019 to April 2019) to current cohorts (January 2020 to April 2020). Notably, cohorts were generated for all patients with neoplasms (malignant, benign, in situ, and of unspecified behavior), with new incidence neoplasms (first encounter), with exclusively malignant neoplasms, and with new incidence malignant neoplasms.

Overall, unambiguous trends were identified which suggested a significant decline in all current cohorts evaluated, with April 2020 displaying the largest decrease in the number of patients with cancer having encounters. More specifically, among the cancer types identified, the lung, colorectal, and hematologic cancer cohorts demonstrated smaller decreases in size in April 2020 versus 2019 (-39.1%, -39.9%, -39.1%, respectively) compared with cohort size decreases for breast cancer, prostate cancer, and melanoma (-47.7%, -49.1%, -51.8%, respectively).

In addition, the investigators also found that mammograms declined 89.2% in April 2020 compared with April 2019, and colorectal cancer screenings declined by 84.5% during the same period. Moving forward, the researchers indicated that they intend to track screenings in the coming months as virus mitigation efforts are eased to help predict how many patients are continuing to delay cancer screenings due to the pandemic.

“The most significant finding in our study was the considerable drop in cancer screenings. The fact that this trend was so drastic nationwide is telling of the widespread effect of the pandemic and mitigation efforts — even in regions that had not seen a significant impact from the virus at the time,” senior author Christopher McNair, PhD, director of Cancer Informatics at SKCC, said in the release.

Throughout the summer and into the fall, the researchers will continue to observe the trends in care of patients with cancer, especially as more states become more drastically affected. According to McNair, it will be important to understand trends in cancer diagnoses to determine if delays in screening are resulting in an increased number of patients presenting with later-stage disease.

“Ultimately, these observed trends have serious implications for future cancer care and validate the need to study and monitor the effect of COVID-19 mitigation on cancer diagnosis and treatment moving forward,” the study authors wrote.

1. London JW, Fazio-Eynullayeva E, Palchuk MB, Sankey P, McNair C. Effects of the COVID-19 Pandemic on Cancer-Related Patient Encounters. JCO Clinical Cancer Informatics. doi:10.1200/CCI.20.00068.

2. Nationwide Trends Show Fewer Cancer Patients Seeking Care Since Start of Pandemic [news release]. Philadelphia. Published July 27, 2020. Accessed July 28, 2020.

These findings have serious implications for future cancer care and underscore the need to resume cancer care and screening.

Nationwide Decrease Seen in Cancer-Related Encounters Due to the COVID-19 Pandemic

While it is known that malnutrition is associated with poorer outcomes in pediatric patients with cancer, oncology nurses were more inclined to under-rate nutritional status, according to a recent study published in the 

The investigators sent electronic surveys to oncology nurses that included patient vignettes that examined nurses’ decision making when it came to nutritional assessment of children over the age of 2 with cancer. Factors included nutritional rating, confidence in rating, and selection of cues that support the nutritional rating. A total of 318 nurses participated.

Nurses rated the vignettes on a scale of 1 to 5, with 1 being undernourished and 5 being over-nourished.  The participating nurses’ answers were then compared to the ratings of a team of experts, comprised of a master’s prepared pediatric oncology nurse, 2 pediatric oncology-registered dieticians, and an epidemiologist researcher of nutrition in pediatric oncology patients.

Nurses chose the same answers as the experts 41% of the time.

“While the mean score of the participants’ ratings were similar to the expert panel, there was considerable individual variation indicating significant differences in clinical decision making between staff nurses and experts,” the researchers wrote.

The nurses that participated were somewhat younger (average 39 years old), more educated (90% had a least a bachelor’s degree and 72% certification rate) and worked in environments known to be high performance settings (66% Magnet® institutions, 86% Children’s Oncology Group). Because of these factors, the study authors predicted that the nurse participants in the study would perform as well as, if not better, than the average nurse in the US.

“The most notable finding regarding the accuracy of participants’ ratings was nurses were significantly more likely to underrate rather than overrate nutritional status,” the authors wrote. “The participants’ ratings, on average, were below the experts’ ratings; the degree of difference increased as the patient depicted in the vignette became more nourished.”

By underrating nutritional status, nurses may be causing certain patients to undergo unnecessary nutritional interventions, putting them at risk for over-nourishment, which could lead to increased risk for morbidity and mortality, the researchers explained.

“Patients being treated for acute lymphoblastic leukemia, the largest portion of pediatric oncology patients, trend toward over-nutriton,” they wrote. “Thus, not recognizing overnutrition in this population could be placing a large percentage of pediatric oncology patients at risk.”

When it came to cue selection, study participants matched the experts only 16% of the time. Notably, the nurses recognized far fewer cues.

“If participants are selecting fewer and/or different cues, it follows that they would determine a different rating of the patients’ nutritional status,” the authors wrote. “Different ratings can lead to different, or no, interventions.”

In particular, participating nurses were far less likely to consider anthropometric variables (height, growth, weight, weight loss). Not only is this important when analyzing nutritional status, but also in properly dosing chemotherapy drugs.

Another discrepancy between nurses and the experts was the consideration of albumin as supporting cues. The experts never selected albumin as a cue, while the nurses selected it more than half of the time (53%).

The findings of this study outlined an important need for oncology nurses to better understand nutritional status in pediatric patients.

“Because nutrition plays a vital role in children’s growth and development as well as their health and healing, oncology nurses need to be well-versed in the nutritional assessment of their patients,” the researchers wrote.

Looking ahead, the researchers said that a standardized nutritional assessment tool for pediatric oncology patients should be implementd. “This can be done through tool development, or through widespread testing, refinement and utilization of the current tools available.”

Lulloff AJ, Vessey JA, Bashore L, Gregas M. Nutrition-Related Clinical Decision Making of Pediatric Oncology Nurses. 

. 2019;36(5):352-360. doi:2083/10.1177/1043454219844233.

Understanding nutritional status and patient cues is crucial in ensuring patients have the proper interventions and treatment plans.
 

Nutritional Status Misjudged by Pediatric Oncology Nurses

Quite simply, there is no good or harm-free exemplar of smoking. Tobacco use entails embarking on a slow course of ruining your life, which is why I am vigilant when it comes to the subject. My father and husband died from cancer caused by long-term tobacco exposure. It is also impossible for me to count how many patients I have cared for over the years who have voiced their regrets for trying that first cigarette.

A disclaimer is in order here. I have never smoked. In 8th grade, we were shown a movie about the dangers of tobacco, which included a graphic picture of blackened lungs that scared me. I went home and made a plea to my parents who both smoked, to stop. For most, however, it is not that simple. Nicotine addiction is extremely difficult to overcome.

Now we have a new tobacco-related epidemic on our hands: vaping. The old record from decades ago about the absence of harm from tobacco has been dusted off and replayed,

but the target for current marketing efforts is different. Children, mostly teenagers, are the focus. The deceit has been so significant that in September of this year, the FDA threatened sanctions against Juul Labs, a major producer of vaping products, for erroneous and misleading marketing to children and teenagers about the “less harmful” nature of e-cigarettes.

Electronic nicotine delivery systems (ENDS) are designed to aerosolize liquids for inhalation. These devices include e-cigarettes, vaporizers, hookah pens, and tank systems, predominantly used to inhale nicotine and cannabis-based compounds. E-cigarettes entered the US market around 2007, and since 2014, they have been the most commonly used tobacco products among youths nationally.

By 2018, there were 288 models of ENDS on the market and more than 15,500 flavors, referred to as juices.4 Vaping behaviors also escalated considerably in high school students between 2017 and 2018.5 An extensive review of monitoring results of over 43,000 students in 8th, 10th, and 12th grades between 2017 and 2018 revealed vaping-related incidences more than doubled in each of these 3 grades. In 2019 alone, the prevalence of vaping in the 30 days before student survey completion was more than 1 in 4 students in 12th grade, more than 1 in 5 in the 10th grade, and more than 1 in 11 in the 8th grade.

 The range of flavor options and the perceptions that vaping is relatively healthy and more socially acceptable than tobacco are considered to be the major drivers in this dramatic increase in use.

As vaping continues to become a widespread issue, many are concerned with its connection to pulmonary diseases. Researchers studied the clinical courses of 53 patients who

were identified in acute-onset pulmonary disease clusters in Wisconsin and Illinois.

Fifty patients were hospitalized, 32% of whom required intubation and mechanical ventilation; 1 death was reported. The median age of these patients was 19 years. All reported e-cigarette device used before the onset of symptoms, the majority of which (84%) inhaled tetrahydrocannabinol products.

Several recent reports detailing biopsy and radiological findings are of particular interest to researchers and public health officials. The acute lung injuries associated with vaping

were primarily identified as hypersensitivity pneumonitis, diffuse alveolar hemorrhage, and histopathologic variations of pneumonia.

 The causes remain speculative, but potential etiologies cited include the aerosolization of flavoring compounds, adulteration of devices with tetrahydrocannabinol-based oils or vitamin E, and use of black market vaping products.

The most recent report of a negative vaping corollary was the development of lung and bladder primary cancers in an animal model where short-term (12 weeks) e-cigarette smoke exposure in mice was associated with the presentation of these malignancies.

The United States needs to set a global example for the prevention of ENDS-related illnesses. To do this, 4 phenomena must be addressed:

1. The young age of ENDS users is of utmost concern. Continuous, unconstrained use of ENDS in this demographic represents the first generation

of teenagers in the modern world to be allowed to put their health and longevity at risk, unchecked, with alleged long- term negative corollaries.

2. The addictive nature of nicotine, especially in young individuals, cannot be ignored. Efforts to protect youth from using nicotine during adolescence is imperative. The developing brain is particularly susceptible to permanent changes from nicotine use.

 Results of epidemiological studies have also shown that smoking in this age group is a first step toward heroin and cocaine addiction.

 Chemical changes in dopamine-receiving neurons induced by nicotine are likely to disrupt the brain’s normal reward circuitry and prime the brain for enhanced sensitivity to potentially abusive substances.

3. Vaping may increase the incidence of dual users of nicotine products. There is growing evidence that rather than substitute conventional tobacco for e-cigarettes, there are more dual users—those who vape and smoke cigarettes.

4. ENDS may be linked to future cases of lung cancer.5 Due to the contemporary nature of this epidemic, the long-term consequences of this health risk are unknown. However, due to historical data associated with nicotine use, it is highly suspect that a link between e-cigarettes and cancer will unfold.

Oncology nurses must keep up with the evolving scientific basis of the perils of vaping.

As trusted educators, we need to maintain informational vigilance about this health hazard. This topic may evolve in discussions with patients as the use of cannabis products during cancer treatment is deliberated. It may also present as patients and families voice concern about their children’s or grandchildren’s use of ENDS. I don’t feel this phenomenon will go away soon, which is all the more reason to focus on our evidence-based astuteness as we advocate for patients and families and perhaps our own loved one.

Marcham CL, Springston JP (2019). Electronic cigarettes in the indoor environment. 

Warning letter to JUUL Labs; accessed 10/10/2019; 

https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/juul-labs-inc-590950-09092019

Surgeon General’s advisory on e-cigarette use among youth. Washington D.C.: Department of Health and Human Services, Office of the Surgeon General, 2018 (

https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018-pdf

Henry TS, Kligerman SJ, Raptis CA, Mann H, Sechrist JW, Kanne JP (2020). Imaging findings of vaping-associated lung injury. 

Author (2019). Vaping-related lung illnesses: Time to act. 

Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME (2019). Trends in adolescent vaping, 2017-2019. 

Layden JE, Ghinai I, Pray I et.al. (2018). Pulmonary illness related to e-cigarette use in Illinois and Wisconsin — Preliminary report. 

Butt YM, Smith ML, Tazelaar HD et.al. (2019). Pathology of vaping-associated lung injury. 

Hswen Y, Brownstein JS (2019). Real-time digital surveillance of vaping-induced pulmonary disease. 

Tang M, Wu X, Lee H et.al. (2019). Electronic-cigarette smoke induces lung adenocarcinoma and bladder urothelial hyperplasia in mice. 

Yuan M, Cross SJ, Loughlin SE, Leslie FM (2015). Nicotine and the adolescent brain. 

Kandel ER, Kandel DB (2014). A molecular basis for nicotine as a gateway drug. 

The Disordered Mind: What Unusual Brains Tell Us About Ourselves. 

Brandon KO, Simmons VN, Meltzer LR et.al. (2019). Vaping characteristics and expectancies are associated with smoking cessation propensity among dual users of combustible and electronic cigarettes. 

Giovenco DP, Delnevo CD (2018). Prevalence of population smoking cessation by electronic cigarette use status in a national sample of recent smokers. 

Tobacco use among young people is an old problem that now challenges a new generation in a new form: vaping.

Vaping Presents an Old Danger to a New Generation

The emergence of biosimilars in cancer care has the potential to relieve some of the financial burden related to drug costs, as well as increase sustainable growth within the field, explained Bradley G. Somer, MD.

“[Biosimilars] is an expanding field, and we have a lot of different options. It is important to dedicate some focus on [biosimilars], because you can come up with the best game plan and best product to implement for your practice,” Somer said. “It's going to be a rapidly developing field as more options become available on a rapid-fire basis.”

, Somer, medical oncologist, senior partner of the Executive Cancer Council, and head of Strategic Expansion/Development of West Cancer Center, and an associate professor in the Department of Hematology and Medical Oncology at the University of Tennessee Health Science Center, discussed the emergence of biosimilars in oncology and their financial implications for patients with cancer.

: What are your thoughts on the approvals of biosimilars in oncology?

: [The arrival] of biosimilars is very exciting because it gives us additional options that are of lesser cost and create a more sustainable system in oncology. The most significant issues in oncology, as we're getting all these amazing advances in cancer therapy, are that the expense and the rate of growth are not sustainable.

We, as a community, need to come up with a game plan in terms of how to make care more affordable and allow us to continue the development of newer therapies, in order to make this explosion something sustainable. Biosimilars are one part of that and hopefully, it's the beginning of more to come. There are other areas, such as comprehensive care, decreasing hospitalizations, and more that could lower costs, but biosimilars will be major in [decreasing the financial strain of] oncology.

How will the availability of biosimilars impact the cost of reference products?

The market share will likely drop in terms of the reference product because people are going to be using some of those biosimilars. Unless there are expanded indications, which hopefully that will continue to be, there will probably be a shift in the metastatic or palliative setting toward these lower cost alternatives.

Has there been hesitancy with physicians getting on board with biosimilars in practice?

When something is new, it always takes time. When you have comfort using [agents] the way that you have been using them, it's hard to veer from that. There is so much to learn in oncology in terms of efficacy and safety, so to veer off into [a value-based approach] is something that your average oncologist or oncology practice isn't going to focus on—unless you're sophisticated enough or have interest to explore that. There is so much information that is out there and our minds are only so big. It's been a challenge that takes a lot of education, strategy and focus from a practice perspective.

What are some ways that physicians can better educate themselves on biosimilars?

In general, [physicians can educate themselves] the same way that they would get educated on anything related to efficacy: using medical education programs. Additionally, when we go to ASCO, ESMO, and other medical conferences, [biosimilar education is] something that has to be front and center. There are comparative studies that are being done, but the conversation has to continue to develop in terms of whether we can go apply [the data with biosimilars to practice]. Where do we stop? That has to be an ongoing conversation.

Ultimately, the decisions have to be made based on what we are doing, [and ensuring] that is best for our patients and society. When we get a patient, we're thinking about that [individual] patient in front of us and we're never going to veer from that. However, as a system—both as a large practice or as a society in general&mdash;we have to think about it more holistically and come up with the best game plan to give the best value, without changing efficacy. As long as there is no change in efficacy, you can get by with the better value option.

For more on financial toxicities, read on 

A version of this article originally appeared on OncLive

Emergence of Biosimilars Poised to Alleviate Financial Toxicity in Oncology

Biosimilars are beginning to change the way oncology professionals treat patients with cancer, and this could help alleviate the financial burden of care. 

Expert Believes Biosimilars Can Help Address Financial Toxicity

October is recognized as Breast Cancer Awareness month, and it is difficult not to notice the theme at every turn, from worldwide landmarks with pink lights—Buckingham Palace, the White House, and Tokyo Tower, to name a few&mdash;to professional athletes altering their uniforms with pink socks, sweatbands, and caps. During this month, you can also find seminars, conferences, and screenings centered around breast cancer. Advertisements on television and social media, too, are loaded with the color pink and the symbolic pink ribbon.

Despite all these efforts to bring awareness to breast cancer, as an African American woman, it is heartbreaking to read the statistics about my ethnic group and the treatment disparity that still exists in 2019. 

 reports that among African American women with breast cancer younger than 50 years old, they have a mortality rate double that of white women with breast cancer.

Not only are more aggressive forms of breast cancer diagnosed in African American women than white women

—such as triple-negative breast cancer (TNBC), which has limited treatments available and can’t be treated with hormonal therapies&mdash;but the disease is being diagnosed at more advanced stages. Contributing factors to these inequalities include social and economic disparities, cultural differences, biological differences, and lack of access to high-quality healthcare. The socioeconomic disparities stem from fewer opportunities and lack of access to resources, such as employment, income, education, housing, healthy foods, and standard of living compared to white Americans. The higher cancer burden may also reflect different rates of behavioral risk factors for cancer such as smoking.

Are we looking close enough at the biological differences? Why are black women more opt to develop TNBC that is most likely not due to a 

 Does socioeconomic status determine the type of breast cancer diagnosed in these women? Could there be a gene mutation expressed in black women that has not yet been identified? In order to dive further into the germline DNA, clinical trials need to include more African American women.

With what we already know, how can we begin to close this disparity gap? I believe knowledge is power and without knowledge, life is lost. Education is key to closing this gap. The American Cancer Society has done a lot of work to bring awareness to underserved communities through prevention and early detection programs and services, by providing transportation to treatment and lodging during treatment, and by assisting with navigation through the healthcare system.

 Community leaders, cancer advocates, health care workers, organizations, associations, and anyone who has an interest in the community must join forces to help bring their own awareness to the unique challenges that African American women with breast cancer face.

The technology is available, and new breakthroughs and treatments are continuing to be revealed, but African American women are not receiving many benefits from these advancements. Much work is still needed to improve the mortality rate and close the disparity gap of African American women with breast cancer.

DeSantis CE, Ma J, GHaudet MM, et al. Breast cancer statistics, 2019 [published online October 2, 2019]. 

Forster V. Breast cancer death rate continues to drop, but black women have far higher mortality rates. 

forbes.com/sites/victoriaforster/2019/10/02/breast-cancer-death-rate-continues-to-drop-but-black-women-have-far-worse-chance-of-survival/#681548922054

Despite advanced technology and new treatment breakthroughs in cancer care, treatment disparity remains among African American women with breast cancer.
 

Prevention