The level of invasiveness surrounding fertility preservation can differ greatly between young men and women with cancer and so oncology nurses should be conscience of this when crafting conversations about family planning with adolescent or young adult patients, according to Donna Herrera Bell, MSN, APRN, FNP-C.

Bell is a nurse practitioner with The University of Texas MD Anderson Cancer Center who spent 14 years working at Children’s Cancer Hospital with children and adolescents with leukemia and lymphoma. Recently, she helped develop a Pediatric Onco-Fertility consult service with MD Anderson.

Following her presentation at the 47th Annual Oncology Nursing Society Congress about eliminating barriers to conversations around fertility preservation in AYA patients with cancer, Bell met with 

® to discuss how nurses can help improve fertility conversations with these populations.

Conversations With Young Men Center on Family Building

“With men, we conduct fertility-risk counseling, we look at what the risks are—according to the type of treatment that they have either received or plan to receive—and then make recommendations about fertility preservation,” Bell explained.

With men, Bell said, fertility preservation is much less invasive and, therefore, fertility conversations should revolve around a young man’s desire for family building in the future. Men who have undergone puberty can bank sperm prior to receiving any type of chemotherapy, radiation, surgery, etc., which may pose a risk to their fertility. However, providers should understand that patients with low-fertility risk and low desire for biological children may choose to forego additional appointments and clinical visits.

“Some young men have never considered [family building, while] some young men have very clear goals about what their desires are for future family building,” Bell said in the interview. “They say, ‘Yes. I want to have biologic children in the future.’”

In contrast, some young men may be open to the idea of adoption or non-biological children in the future and may feel that navigating a sperm bank is too much of a burden while also undergoing a cancer diagnosis. The important thing for an oncology nurse to emphasize to these patients is that once treatment has begun, the window for fertility preservation has closed.

“A great example is for young men with acute myeloid leukemia,” said Bell. “Their initial chemotherapy is going to be low risk in terms of fertility. However, if they do not respond [to frontline chemotherapy,] their treatment will change, and will usually require more aggressive treatment, which will change that risk of fertility for them, but the window to preserve fertility will have already closed since they’ve started chemotherapy.”

Therefore, it is important for nurses to have those candid conversations with young men, she emphasized, and to make it clear that those risks may change.

Young Women Must Consider Timeliness and Invasiveness of Procedures

Fertility preservation for women is both more invasive and more time consuming than that for men—meaning that the decision can become a bit more complex for females.

“Fertility preservation for women is invasive,” said Bell. “It involves oocyte retrieval, where medications are given so the ovary will mature an oocyte for retrieval.”

Unfortunately, this process takes at least 14 days to complete which, in turn, can mean that women must delay their cancer treatment by at least a couple weeks to undergo the oocyte retrieval process. This delay can represent a significant barrier to women considering fertility preservation, especially if their cancer is advanced and their oncologists feels that that it’s not safe to delay treatment by 2 weeks. Therefore, cancer stage and fertility risk are important conversations to have with young women during this process.

Similar to men, different treatment types pose different fertility risks: if the ovary will be undergoing radiation, this may pose a risk as different chemotherapies represent different degrees of potential harm. However, unlike men, age may also play a role in determining risk in adolescent or young adult women.

“Girls are born with all the eggs we are going to have, and we don't ever make any more,” explained Bell. “Our window of fertility opens at puberty, and it closes at menopause. Usually around age 50.”

For older women, in their late 20s or early 30s, for example, the ovarian reserve is already lower than that of a 16-year-old woman. Thus, the older a woman is means she is more sensitive to fertility risk than one who is younger. Age is also an important factor to consider as well, she explained.

Once again, Bell suggests asking patients the following questions: “What are your family building goals? Have you thought about what you want your family to look like? What are options that you are open to pursuing?”

“Having those individual discussions with patients, partners, and families, is really key to helping that adolescent or young adult feel like this is not something that's being taken from them,” she said.

Many young adults that Bell meets feel as though fertility is 1 more thing that cancer has jeopardized for them. Therefore, it is vital that providers take the time to ensure that patients understand their potential risks, and options available to them, to decrease any potential decisional regret they may feel as survivors.

Unfortunately, fertility preservation for young patients is not covered by most insurances. Some organizations help to cover some of these costs; however, even with these resources, a procedure such as oocyte cryopreservation may still be close to $7000 out of pocket for a patient—a patient who only recently received a cancer diagnosis.

Although not everyone may be able to afford fertility preservation procedures, every provider can afford to take the time to have a meaningful conversation about these options with newly diagnosed patients, according to Bell.

“Everyone can have this discussion, and every patient should feel empowered about making these decisions and having this choice,” she said.

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Conversations surrounding fertility preservation may differ between young men and women with cancer, according to Donna Herrera Bell, MSN, APRN, FNP-C.

How To Approach Fertility Conversations With AYA Patients as an Oncology Nurse

Oncology nurses can help reduce the number of central line-associated bloodstream infections (CLABSIs) in patients undergoing hematopoietic stem cell transplant (HSCT) by standardizing central venous catheter (CVC) blood draws and chlorhexidine gluconate (CHG) treatment usage, according to a presentation at the 2022 Transplantation & Cellular Therapy Meetings.

Following a peer-to-peer observation and validation process was implemented in June 2021, there was a 68% decrease in CLABSI incidences at NYU Presbyterian 10 West. The number of incidences improved from 2.82 events per 1000 central line days (pre-intervention January to May) to 0.90 events per 1000 central line days (June to August).

“Oncology nurses play a primary role in implementing strategies to help reducing preventable CLABSI,” Thanyanee McNinney, BSN, RN, OCN, of the New-York Presbyterian Department of Nursing, said in a poster presentation of the findings.

CLABSIs represent a significant mortality risk to patients and are also linked with financial toxicities; one case of CLABSI can cost around $40,000.

Furthermore,factors including long term central line placement and usage, high-dose chemotherapy, prolonged immunosuppression, and the possibility of posttransplant complications such as graft-vs-host-disease (GVHD) mean that patients undergoing HSCT are especially vulnerable to CLASBI. However, research has demonstrated that proper insertion techniques and central line management can help prevent CLABSI.

In 2020, there were 0.51 CLABSIs per 1000 central line days at the investigator’s institution; by the second quarter of 2021, there were 2.82 CLABSIs per 1000 central line days.

Therefore, investigators sought to increase competency and reduce the incidence at their institution. Their objective was to reduce incidence by 20% within 3 months on a 16-bed HSCT inpatient unit in an academic medical center.

Investigators collaborated with the Hospital Acquired Infection (HAI) champions and nursing leadership teams to develop an action plan. This plan consisted of a thorough root to cause analysis of incidences, interdisciplinary huddles, standardized validation tools to allow peer-to-peer observation and validation during blood culture and blood specimen collection via central lines and CHG use.

The CVL peer feedback tool assessed whether observed staff performed proper hand hygiene when indicated, needle endcaps were clean, CVC ports/lines not being used had an alcohol impregnated endcap in place, all intravenous (IV) tubing not being used had a red cap, that no IV tubing were expired and had adequate labels indicating last line change, and that the CVC dressings were clean, intact, and not reinforced.

Following peer-to-peer observation and validation, it was revealed that 35% of nurses did not adhere to NYP policy when collecting blood cultures or drawing blood via a central line. Furthermore, 66% of nurses did not know how to perform CHG treatments correctly.

In addition, the study revealed multiple opportunities for growth. Among some of the registered nurses, peers observed the donning of gloves without performing hand hygiene, opening equipment without proper aseptic technique; insufficient scrubbing of the hub, failure to replace new Q-site prior to drawing blood cultures, drawing blood cultures directly through the lumen without a new Q-site placement, and a failure to flush with required amount of normal saline post-blood draw and performing push-pause technique when flushing.

Ultimately, nurses can be pivotal in reducing CLABSIs by educating staff members on proper CHG wipe usage and standardizing central line blood draws. These efforts are consistent with the “zero harm” initiative adopted at various institutions and represents a commitment to providing a safe and caring environment for patients and staff by eliminating all preventable patient injuries and infections.

McNinney T, Roselli T, Miner D. Reducing central line-associated bloodstream infections (CLABSI) through standardizing central venous catheter (CVC) blood draws and chlorhexidine gluconate (CHG) treatment usage. Presented at: 2022 Tandem Meetings Transplantation & Cellular Therapy Meetings of ACTCT and CIBMTR; April 23-26, 2022; Salt Lake City, UT. Abstract 612. 

Oncology nurses at the 2022 ASTCT Meeting shared how a peer-to-peer observation and validation tool helped decrease central line-associated bloodstream infections by 68%.



Oncology Nurses Drastically Reduce Central Line Infection Incidences Through Peer-to-Peer Observation Strategy

A nurse-driven program successfully connected patients undergoing chemotherapy with scalp cooling treatment, according to results that were presented as a poster during the 47th Annual Oncology Nursing Society Congress. Furthermore, patients who completed the program expressed high satisfaction levels with scalp cooling and retained 50% more hair than anticipated with this type of treatment.

Overall, 15 patients elected to undergo scalp cooling therapy and more than 80 treatments were administered since June 2021. Although 2 patients stopped treatment because they felt overwhelmed, patients who completed all cycles expressed high levels of satisfaction, according to the study authors. In addition, the nursing staff reported satisfaction with the amount of training and resources provided during implementation and “are proud” that scalp cooling is offered at their institution.

Many patients expressed gratitude for being connected to the therapy through testimonials.

“It really sucks to go through cancer treatment, I am so glad I had scalp cooling… I am so appreciative I was given the chance to save my hair and keep a part of my identity,” 1 patient shared during a testimonial.

“Nurses are at the forefront of promoting and educating patients throughout the care continuum for supportive care interventions, such as scalp cooling,” Linda Amacher, BSN, RN, OCN, of Froedtert & the Medical College of Wisconsin, addedin a presentation of the findings. “[In this case,] there was quick adoption by nurses, and processes were integrated into clinic and infusion workflows without significant challenges.”

More than 75% of patients with cancer fear experiencing alopecia because of chemotherapy. Since scalp cooling was FDA approved in 2017, patients and oncology care teams have become interested in its ability to 

Following favorable efficacy and safety data with scalp cooling, a team of oncology nurse decided to pilot a scalp cooling program at a community-based cancer center connected to the Froedtert Medical College of Wisconsin.

Investigators created an interprofessional team to oversee the program implementation. The team was led by an oncology clinical nurse specialist and included other nurses, providers, a scheduler, managers, and aesthetics wellness coordinators. The members were tasked with evaluating costs, machine support, space, scheduling, and staff workload. They also set to create roles, workflows, scheduling templates, nursing documentation texts, patient education, and evaluation tools.

Staff training included a demonstration of how scalp cooling works, the clinical data and efficacy behind it, and cooling machine system procedures, including patient introduction and education. Nurses and aesthetic coordinators specifically learned about patient enrollment, prescription, consent, cap fitting, system operation, and patient hair care and education materials.

Having an advanced practice nurse—driven program was a key to successful implementation, the authors concluded, noting that overall, the implementation was successful and well received.

“Patients that have completed all treatments have expressed high satisfaction on our evaluation forms and are happy to report retaining more than 50% of the hair expected,” concluded Amacher. “Staff have also expressed satisfaction in the amount of training received resources provided and are proud that we offer scalp cooling.”

Other cancer centers may wish to consider program development using a nurse-driven model, Amacher added.

Amacher L, Herriges D, Portz D, et al. Hairs the deal: implementing scalp cooling for chemotherapy-induced alopecia at a community-based cancer center. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA. Abstract P44.

A nurse-led intervention demonstrated initial success in connecting patients to scalp cooling therapy and reducing the impact of alopecia.

Nurses Help Bridge Patients Undergoing Chemotherapy to Scalp Cooling Therapy 

Non-drug therapies such as cognitive therapies may be useful for cancer survivors experiencing insomnia. However, more research is needed to determine benefit in patients with advanced-stage cancer and those undergoing active treatment, according to results of a study presented at the 47th Annual Oncology Nursing Society Congress.

Eugenie Spiguel, a nurse practitioner in integrative medicine at Memorial Sloan Kettering Cancer Center in New York, explained that patients with cancer often experience insomnia at a rate of two or three times higher than the general population. And it is often treated with medication, which is not always suitable for patients who do not want an added mediation and the potential side effects that come along with it.

The American College of Physicians recommends cognitive behavioral therapy as first-line treatment for insomnia, and Spiguel sought to evaluate if this was an effective treatment option for patients with cancer based on previous studies.

cognitive behavioral therapy for insomnia

. The studies included methods such as group therapy, telemedicine and shortened versions of the typical visits for cognitive behavioral therapy (from six visits to two).

“By and large the findings were overwhelmingly positive, so there was an improvement in many insomnia parameters,” Spiguel said during the presentation. Improvements were observed in the time it took to fall asleep, the ability to stay asleep and waking up early.

 and not patients currently undergoing treatment.

“And that is unfortunate only in that we already know that it’s effective in the general population, (and) the survivorship population coincides with that,” she said. Spiguel hopes that patients undergoing active treatment can be included in future studies.

“I would love to see more research done on patients who are undergoing treatment or in the advanced cancer (stage) population,” she added.

She concluded in saying that treating insomnia in patients with cancer is easy to implement into daily practice and is rewarding.

“If we find that patients are having insomnia, we can easily intervene with a non-drug therapy. I do this myself in my own clinic and it is extremely rewarding to see somebody improve, to see their insomnia really get better,” Spiguel concluded.

Spiguel E. Cognitive behavioral therapy for insomnia comorbid with cancer. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA. Abstract P313.

Cognitive therapies were found to be effective for helping cancer survivors with insomnia, but more research is needed for patients actively receiving treatment. 

Cancer Survivors Struggling With Insomnia May Benefit from Cognitive Therapy 

Death doulas may be able to fulfill an unmet need and bring quality end-of-life care to patients with cancer. However, institutions should seek to ensure that the funding is sufficient to make this service available to those who need it, according to results of a poster presented at the 47th Annual Oncology Nursing Society’s Annual Congress.

The addition of death doulas to end-of-life care teams has represented a novel change in care in this setting, the study authors explained. The role of these caregivers is similar to that or a birth doula; instead of supporting labor, these individuals help patients with a terminal illness navigate their dying process.

The death doula provides the opportunity to combat the medicalization of dying and to instead offer an individual the ability to bring choice, autonomy, and person-centered care into their dying process. These professionals bring knowledge of community-based, traditional, and culturally safe practices to the process.

The Canadian Hospice Palliative Care Association’s 2013 Square of Care could potentially be used as a framework to help ease the inclusion of death doulas into their interactions with oncology nurses, according to the presented literature review.

The square of care helps healthcare providers address the following issues that patients may face; the framework requires them to take an assessment of the patient’s disease management, physical, psychological, social, spiritual, and practical well-being, as well as their end-of-life/death management, and loss or grief.

The guide then outlines the process of providing care for these issues. The process includes assessment, information sharing, decision-making, care planning, care delivery, and confirmation. Importantly, the patient and the family are at the center of the square, and their needs determine the issues that need to be addresses.

This model helps provide a road map for excellent hospice and palliative care. When used correctly, the goalposts outlined in the model help to shape care plans in a fashion will not overwhelm team members.

In the presentation, Lorraine Holtsland, PhD, RN, CHPN, outlined how the oncology nurse and death doula might work together under the conceptual square of care framework.

“We used the CPCSA framework because it helps to explain the roles and how they might work together within that model of care,” Holtsland said.

“The role of the oncology nurse is focused on assessment, and supporting medical needs treatments, care planning, and care delivery. Whereas the death doula can really focus on building relationships that allow for advanced care planning, sitting vigil with families, supporting a home death, and home funerals, [and even] different options like a green burial,” she added. “It really depends on that relationship and [the patient’s] goals and values.”

Over the next 10 years, there will continue to be many cancer-related deaths. “The death doula can help to fill many gaps” Holtsland said. “As they provide support for patients and families to remain at home and in their communities. A concern is access to funding and accessibility of these services to everyone.”

A good goal for the oncology community would be that the death doula would become part of the healthcare team and that everyone, whether they can afford such services or not, be able to have access to these services, she concluded.

Holtsland L, Hall St. Improving end-of-life care through interprofessional collaboration with death doulas: Implications for oncology nurses. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA. Abstract P44.

The death doula is a unique role that can help oncology care teams improve the quality of end-of-life care delivered to patients.

Incorporating a Death Doula into the Oncology Care Team

The diarrhea stoplight assessment (DSAT) tool represents a new cost-effective and user-friendly patient education platform to assist nurses in identifying and managing early cancer treatment–induced diarrhea, according to findings that were presented at the 47th Annual Oncology Nursing Society Congress. However, further research to apply the results in a larger data set of patients is still warranted.

The stoplight format of the patient education tool included 3 different zones: green, red, and yellow. Each color was associated with different interventions, and these tools are associated with improved symptom management and reduced readmissions for chronic diseases.

Ultimately, an analysis of hospital T-tests found that 30-day hospital readmissions were reduced in the intervention group (

<.001). Readmission rates were also lower in the retrospective group.

A follow-up analysis of the post-intervention group found that patients averaged 8.5 visits with reported chemotherapy-induced diarrhea (CID) stoplight levels (green, 92.4%; yellow, 5.70%; red, 1.9%)

In addition, activities of daily living were determined to be the life aspect most affected by bowel changes. On a scale where 0 represented “no impact” and 10 represented “extreme Impact,” the average score reported for activities of daily living (ADL) with bowel changes was 3.79. In comparison, the average score for energy was 1.52, mood was 1.86, family life was 1.26, and social life was 1.67.

“Research shows that diarrhea is a common side effect of chemotherapy treatment, and it can be a dose-limiting toxicity for many,” lead study author Rebecca Kirkpatrick, BSN, RN, OCN, Meritus Medical Center explained in a presentation of the findings. “Literature indicates that 50% to 80% of patients can develop diarrhea associated with their treatment, resulting in [emergency department] visits, 30-day hospital readmissions, and delays in their cancer treatment, potentially affecting their overall survival.”

“We found that the stoplight tool was effective in reducing 30-day admissions by [reducing] chemotherapy-induced symptoms at home,” she added. “Reduction of readmissions is important for immunocompromised patients by reducing costs and improving patient satisfaction and outcomes.”

Although previous research has shown that stoplight tools have been useful in helping patients manage chronic diseases, investigators noticed that there was insufficient research documenting the efficacy in patients with cancer.

Therefore, this study assessed the impact of the CID stoplight tool on hospital readmissions and emergency department (ED) visits over a 30-day stretch. The analysis included a retrospective chart review and post-survey. Overall, the study assessed 25 participants with cancer who received the intervention.

In the spotlight tool, a green day was described as a “good day.” This zone signifies that a patient has no increase in bowel movements over baseline and no changes in stool color or consistently. A green day also means that a patient can consume fruits and vegetables normally. Patients in this zone were advised to continue their normal activities, maintain their normal diet, and keep all regular doctor appointments.

A yellow day was described as a “bad day.” This zone signifies that a patient has experienced an increase in bowel movements over baseline and their stools are more liquid than normal. Patients experiencing a yellow day are not able to eat and drink normally and are experiencing stomach cramps or aches. The DSAT tool advises patients in the yellow zone to take diarrhea medication as instructed by their provider, stop using any laxatives or stool softeners, drink fluids, avoid fiber or other inflammatory foods, keep their skin clean, and to call their doctor as symptoms worsen.

A red day was described as a “very bad day.” This zone signifies that a patient is experiencing more than 4 bowel movements per day over baseline and these stools are completely liquid. Patients in the red zone are unable to make it to the bathroom on time, are experiencing severe adnominal pain, and are unable to eat and drink. These patients are also not experiencing any benefit from diarrhea medication. The DSAT tool advises patients in the red zone to call their doctor immediately: if they cannot reach their provider within 1 hour, they should visit the ED; if the patient cannot drive themselves to the ED, they should call 9-1-1.

Prior to initiating chemotherapy, participants identified CID zones at each treatment visit and at home as a guide for symptom management with assistance from their oncology nurses. Nurses were provided with the Systematic Therapy Induced Diarrhea Assessment Tool (STIDAT): a reliable diarrhea assessment tool used to monitor symptoms and CID impact on quality of life.

Thirty days after implementation, hospital readmission and ED visits data were collected though chart reviews.

“The DSAT was a cost-effective and patient-friendly education tool for nurses for early use of identification and management of chemotherapy induced diarrhea in the oncology population,” Kirkpatrick concluded.

Study authors noted that the project began at the start of the COVID-19 pandemic, which potentially limiting outcomes, adding that a confirmatory study with a larger sample size is warranted.

Kirkpatrick R, Rineheart V, Bert K, et al. Implementation of an evidence-based patient education stoplight tool to reduce cancer treatment-induced diarrhea. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA. Abstract P340.

A patient-friendly stoplight tool with 3 different colored zones helped patients undergoing chemotherapy manage diarrhea and reduce hospital and emergency department visits. 

 Stoplight Tool Helps Patients Manage Chemotherapy-Induced Diarrhea, Reduces Hospital and ER Visits

Medical cannabis in conjunction with opioids may be an effective treatment strategy to reduce pain burden in patients with cancer, according to a presentation at the 47th Annual Oncology Nursing Society Congress.

Furthermore, health care providers should continue to educate patients and caregivers about the potential benefits and risks associated with medical cannabis, and keep them informed with current available evidence and emerging data to recommend efficacious dosing and formulations.

In doing so, nurses can proactively care for patients experiencing pain burden by identifying which patients might benefit from this treatment based on current conditions, symptomology, and efficacy of previous therapeutics, according to Amber Nenner, BSN, RN; Felita Salim, BSN, RN, OCN; and Ryan Sandler, MS, RN, all of the Columbia University School of Nursing, who presented on the findings in a poster during this year’s meeting. 

The authors noted that there is a wide range of symptoms that can affect patients with advanced cancer, including chronic pain, anorexia, chemotherapy-induced nausea and vomiting (CINV), anxiety, and diminished quality of life (QOL). Notably, Dronabinol, a pharmaceutical form of delta-9-tetrahydorcaanobinol and Nabilone, a synthetically made cannabinoid, are FDA approved to treat patients with certain conditions, including CINV.

However, cannabis use continues to remain controversial and best practices surrounding its use remain unclear.

In data presented at the ONS Congress, investigators conducted a literature review to determine the efficacy and safety of medical cannabis as a treatment strategy in oncologic supportive care.

“We felt it was very important to this patient population to seek out research about this treatment option,” Nenner explained in a presentation of the findings. “Specifically, we wanted to discover the current evidence on the effects of cannabis on pain, anorexia, nausea, vomiting, anxiety, and quality of life.”

Study authors searched across Pubmed, CINAHL, and Embase with the following search terms, “cancer AND marijuana,” “oncology AND medical cannabis,” “marijuana AND cancer symptom relief,” “marijuana AND chemo-induced nausea and vomiting,” “medical cannabis AND chemo-induced nausea,” “cancer AND medical cannabis,” and “medical cannabis AND cancer symptom relief.”

Studies were excluded if the participants were under 18 years of age, had preexisting chronic conditions, or non-cancer–related pain.

In a prospective cohort study by Anderson et al, investigators enrolled 1120 patients with cancer in a Minnesota MC program.

 These patients were administered a legally purchased 30-day supply of MC that was purchased out of pocket. A total of 743 patients were included in the analysis.

The findings revealed that patient experienced a significant reduction in anxiety, their lack of appetite, depression, disturbed sleep, fatigue, nausea, pain, and vomiting from baseline to 4 months. However, 10.5% of patients also reported drowsiness and dry mouth.

This study was limited by response bias, a lack of control group, limited validated tools, confound variables, and a lack of exclusion criteria.

The second analysis, by Boland et al, was a systematic review and meta-analysis of randomized controlled studies, which evaluated 6 studies in its review and 5 studies in the meta-analysis.

 Patients had chronic cancer pain and were on regular opioids. These patients received cannabinoids via any route vs placebo or other analgesia.

Overall, there was no mean difference in pain between cannabinoids vs placebo and adding cannabinoids to opioids was not found to augment pain reduction. There was also a higher risk of adverse events (AEs) in the cannabinoids arm vs the placebo arm: patients receiving cannabinoids experienced somnolence and dizziness.

This study was limited by pain scale use, high attrition rate, and confound variables.

In an Australian, randomized, double-blind, placebo-controlled phase 2/3 trial by Grimison et al, investigators assessed 81 participants with refractory CINV, despite antiemetic prophylaxis during emetogenic intravenous chemotherapy.

 Cycle A involved 1 to 4 self-titrated oral THC:CBD 3 times daily for days 1 to 5, while cycle B involved matching placebo crossover design. Cycle C assessed blinded patient preference.

Compared with placebo, THC:CBD was associated with significantly decreased nausea, vomiting, use of rescue medications, and improved QOL in physical and mental health.

However, 31% of patents reported AEs with THC:CBD vs 7% of patients on placebo. Overall, 83% of patients preferred TBH:CBD and 15% of preferred placebo.

Limitations for this study included the crossover design, as well its possible non-representative sample, and confound variables.

A retrospective chart review, by Pawasarat at el, evaluated 232 patients enrolled in the State of New Jersey Medicinal Marijuana program, 137 of whom received medical marijuana and 95 of whom did not.

 Electronic health records were reviewed to identify instances of pain, tiredness, appetite, drowsiness, depression, anxiety, and shortness of breath.

Findings concluded that there were no significant differences between the 2 arms; however, the arm without marijuana required 63% more daily opioids to manage their pain.Investigators determined that conjunction marijuana use can delay the need and intensity of opioids treatment.

Study limitations included confound variables and limited application to solid malignancies.

In a double-blind, randomized, phase 2 trial, by Schloss et al, enrolled 88 patients with high-grade glioma to assess the tolerability of oral THC:CBD plus standard treatment for 12 weeks.

 Patients were randomized 1:1 to receive THC:CBD/standard treatment or a 4:1 ratio of THC:CBD.

Data revealed that a nightly dose of THC MC (preferably 1:1) was safe, linked to no serious AEs, and significantly improved sleep quality, functional well-being, and QOL.

Limitations included the lack of placebo, high attrition rate, cohort heterogeneity, short follow-up, and possible outcome bias.

A pilot retrospective chart review by Zylla et al used a state-sponsored MC program that assessed 30 patients, 15 of whom received standard cannabis treatment and 15 of whom received delayed cannabis treatment.

 Participants were queried on scales of pain, side effects, and overall satisfaction.

Overall, patients who received earlier cannabis treatment reported improved pain levels and a 20% reduction in opioid usage. In contrast, the patients who received delayed cannabis needed a 57% increase in opioid use for pain management.

Limitations for this study included a small sample size, no placebo or binding, response bias, high attrition rate, and a limited analysis.

Will Medical Cannabis Replace Opioid Use?

The cumulative evidence does not suggest that medical cannabis will replace standard opioid therapy, the authors concluded. However, it was found to be an effective adjunct among those who were opioid refractory, and helped to reduce the overall need for opioid consumption by reducing pain intensity.

In addition, THC:CBD formulations improved the conditions of patients with CINV, and THC:CBD tablets increased the weight and appetites of patients with anorexia and cachexia. The wide range of cannabinoid receptors on the body ultimately responded to the drugs and resulted in improved QOL by improving sleep, depression, and anxiety.

Common AEs associated with cannabis included CNS, dizziness, somnolence, disorientation, gastrointestinal disturbances, hallucinations, and altered functional status.

Finally, the authors noted that most studies had no uniform dosing strategy and presented a variety of routes, cannabis products, doses, and high attrition rates.

“Results from these [studies] are anecdotal at best; further, high-quality studies are needed to create standardized guidelines for clinical application,” Nenner summarized.

“It is important to identify which patients may benefit from medical marijuana as it may alleviate symptom burden in conjunction with standard therapies. However, nurses must assess the current legal guidelines in their states and educate patients and caregivers of its benefits and risks to facilitate shared decision-making,” Salim added.

Nenner A, Salim F, Sandler R, et al. Cannabis and symptom management in cancer, efficacy, and implications for clinical use. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA. Abstract P4.

Anderson SP, Zylla DM, McGriff DM, Ameson TK. Impact of medical cannabis on patient-reported syndromes for patients with cancer enrolled in Minnesota’s Medical Cannabis Program. 

. 2019;15(4).e338-e345. doi:10.1200/JOP.18.00562.

Boland EG, Bennett MI, Allgar V, Boland JW. Cannabinoids for adult cancer-related pain: systematic review and meta-analysis. 

. 10(1),14-24. https://spcare.bmj.com/content/10/1/14

Grimison P, Mersiades A, Kirby A, et al. Oral THC:CBD cannabis extract for refractory chemotherapy chemotherapy-induced nausea and vomiting: a randomized, placebo-controlled, phase II crossover trial. 

. 2020;31(11):1553-1560. doi:10.1016/j.annonc.2020.07.020.

Pawasarat IM, Schultz EM, Frisby JC, et al. The efficacy of medical marijuana in the treatment of cancer-related pain. 

. 2020;23(6):809-816. doi:10.1089/jpm.2019.0374

Schloss J, Lacey J, Sinclair J. A phase 2 randomized clinical trial assessing the tolerability of two different ratios of medical cannabis in patients with high grade gliomas. 

. 2021;11:649555. doi:10.3389/fonc.2021.649555.

Zylla DM, Eldund J, Gilmore. A randomized trial of medical cannabis in patients with stage IV cancers to assess feasibility, dose requirements, impact on pain and opioid use, safety, and overall patient satisfaction. 

 2021;29(12):7471-7478. doi:10.1200/JCO.2019.37.31_suppl.109.

Patients who receive medical cannabis in addition to standard opioids may require less overall opioid treatment to manage their pain.

Cannabis Use May Help Decrease Opioid Need in Patients With Cancer

Very low dose radiation therapy (VLDRT) was found to be an effective treatment approach in the palliative setting for patients with indolent non-Hodgkin lymphoma, but it is not considered a standard of care in this patient population, according to findings presented at the 47th Annual Oncology Nursing (ONS) Congress.

Additionally, a benefit of VLDRT is that it allows retreatment to the same field as needed. While radiation-related toxicities were low in both VLDRT and standard radiation (RT) therapy groups, the shorter treatment schedule of 2 treatments vs 12 treatments is also a quality-of-life benefit in the palliative setting.

Preparation for either radiation dosing approach, as well as the timetable of scans to determine response to treatment, remains the same.

The goal of the research was to close the gap in oncology nursing literature and define the role of VLDRT in patients with indolent lymphomas, Catherine Adams, BSN, RN, OCN, of Memorial Sloan Kettering Cancer Center, and coinvestigators, wrote in the poster presentation.

“Standard treatment can be started immediately if VLDRT is not effective for control of localized disease,” the authors wrote. “VLDRT does not compromise future types of treatment.”

Indolent lymphomas, specifically follicular lymphomas and marginal zone lymphomas, are known to be very radiosensitive. Historically, patients with these malignancies have been treated with radiation doses at 40 Gy to 45 Gy for a total of 20 treatments.

Previous research has shown that 24 Gy for 12 treatments was also found to be effective for disease control in patients with localized follicular lymphoma.2 Additionally, data from the FORT trial (NCT00310167), which compared the use of 24 Gy with 4 Gy, showed that 24 Gy should be standard of care, though 4 Gy remains an optimal alternative in the palliative setting.3

In the poster presented at the ONS Congress, the authors noted that the preparation for VLDRT is the same as standard 24 Gy. They also referred to retrospective data from 1994 to 2017,4 which compared the early and late toxicities of patients who received standard vs VLDRT to nonorbital head and neck fields, which included the oral cavity, nasal cavity, salivary glands, sinuses, Waldeyer’s ring, and nodal disease.

The retrospective findings showed that the toxicities rates were significantly lower for the nonorbital head fields with VLDRT (n = 17) vs standard radiation (RT; n = 51) regarding dermatitis, xerostomia, dysgeusia, mucositis, esophagitis, site pain, anorexia, nausea, alopecia, dysphagia, and edema.

The findings were similar for the neck field for those who received VLDRT (n = 18) vs standard RT (n = 80); rates of dermatitis, xerostomia, esophagitis, dysphagia, hoarseness, mucositis, dysgeusia, alopecia, and nausea were all lower with 4 Gy.

Further patient benefits of VLDRT include “decreased time requirements for the patient to complete treatment, decreased disruption to patient/family life and work schedule, and decreased financial burden related to travel cost, child-care expenses, and potential loss of work for patient and/or family members,” the authors concluded in the poster.

Adams C, Cho G, Yahalom J, et al. "Boom-Boom" very low dose, 2 fraction radiation therapy for the treatment of indolent non-Hodgkin lymphoma in the palliative setting. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA. Abstract P6.

Lowry L, Smith P, Qian W, et al. Reduced dose radiotherapy for local control in non-Hodgkin lymphoma: a randomised phase III trial. 

. 2011;100(1):86-92. doi:10.1016/j.radonc.2011.05.013.

Hoskin PJ, Kirkwood AA, Popova B, et al. 4 Gy versus 24 Gy radiotherapy for patients with indolent lymphoma (FORT): a randomised phase 3 non-inferiority trial. 

. 2014;15(4):457-63. doi: 10.1016/S1470-2045(14)70036-1.

Chelius M, Chau K, Yang J, et al. Low grade, indolent lymphomas of the head and neck: Comparative toxicity of standard versus very low dose radiation therapy. 

. 2021;39(3):304-312. doi:10.1002/hon.2865

Very low dose radiation therapy was found to be an effective treatment approach in the palliative setting for patients with indolent non-Hodgkin lymphoma.

Very Low-Dose RT Is Effective, Although Not Standard in Indolent Non-Hodgkin Lymphoma

Although not every patient with cancer will experience a sexual health crisis during treatment, every patient with cancer will experience some form of sexual health change, according to Sage Bolte, PhD, LCSW, CST. Therefore, it is important that oncology nurses establish that they are someone a patient can turn to if, and when, they want to discuss issues related to their sexual health.

“Every single one of them will have sexual changes,” Bolte, chief philanthropy officer and president of the Inova Health Foundation, said. “They will have questions, whether it's during treatment, after treatment, or 3 years after treatment. [Nurses] will be the one that they reach out to so that they don't feel scared and isolated and confused when those issues come up.”

“[With some populations], it is still not necessarily generationally appropriate [to have these conversations], and it may be uncomfortable for them,” she added. “So, it is [often] our providers [who need] to be the ones to bring forward the conversation.”

In a presentation during the 47th Annual ONS Congress, Bolte, along with Elaine Wittenberg PhD, FACH, an associate professor at California State University, and Joy Goldsmith, PhD, a professor of health communication at the University of Memphis, discussed effective communication strategies for oncology nurses addressing sensitive topics with their patients.

To better engage with their patients, oncology nurses may need to ask themselves: “What is my comfort level discussing sexual health?” and “What are my particular strengths in helping patients and their partners reclaim their own bodies?”

Nurses may also need to reflect further and ask themselves how comfortable they are with their own body and sexuality, their own positive image, and whether they are themselves at a place of peace to overcome their own personal barriers and initiate these conversations.

“It is OK if you're uncomfortable with those words,” Bolte noted. “We're taught to be a little uncomfortable with those words. [But], we have to look at what triggers that discomfort so we can show up for our patients without showing that discomfort.”

Furthermore, nurses can help promote more meaningful dialogue by keeping the conversation patient centered and positive. For example, Bolte says it is a better approach to tell a patient, “Cancer and its treatments have such significant impacts on all aspects of our lives, including our sexual health–this is normal. I would love to provide you with some information” rather than telling them, “You can discuss sexual failure with me” or “I am trained not to laugh.”

Overall, Bolte recommends looking for “very simple, non-threatening ways to open a conversation with the information that [the patient] is providing.”

To best address these issues, Bolte recommends the “Ex-PLISSIT Model” as an ideal approach. The ex-PLISSIT model calls for health care providers to:

ermission at every stage and every visit to assess and inquire about a patient’s sexual health;

nformation, guide them towards resources such as written information and available education;

herapy, if necessary, as well as to keep a current network for patient referrals.



In addition, Bolte also highlighted the following useful conversation starters to aid oncology nurses who may feel uncomfortable beginning these discussions:

Is there anything that would be important for us to know about your sexual history or sexual health to best support you during the time we are caring for you?

What concerns or questions do you have about changes in or the continuation of your sexual needs?

In what way has your sexual relationship(s) with your partner(s) or self changed?

What information or resources can I provide to help you improve your sexual health?

It is important to note that the impact of cancer on sexual health may not always be transparent. Beyond the cancer itself, there is often a pressing psychological distress related to the diagnosis and treatment on both the patient and their partner. Different treatments yield different side effects and alterations as well, and can impact relationships during and after treatment, Bolte said.

Some common physiological changes from therapy-related adverse effects (AEs) that male patients with cancer experience include chemo-brain, joint discomfort, neuropathy, and hair loss, among others. Neurovascular damage stemming from chemotherapy, radiation, or surgery is also common and can result in erectile disorder (ED). Endocrine changes can reduce testosterone levels and result in reduced libido, osteoporosis, and vasomotor flushing, and physical stamina can be affected, as well.

Lastly, penile length may be reduced, infertility can occur, and body image changes may emerge.

The most important thing that an oncology nurse can do to help a patient navigate their sexual health is repeatedly offer them permission to have conversations surrounding their health.

Supportive Care