Anemia is a common problem with myelofibrosis and can lead to a significant patient burden, according to Aaron T. Gerds, MD, MS. However, JAK inhibitors have demonstrated encouraging efficacy in this arena.

Gerds, who isan assistant professor in medicine (hematology and medical oncology) at the Cleveland Clinic Taussig Cancer Institute, recently presented findings from the phase 3 MOMENTUM trial (NCT04173494), which showed that in the open-label continuation phase, patients with myelofibrosis who have anemia and previously received a JAK inhibitor who stayed on momelotinib experienced durable transfusion independent, splenic response, and symptoms improvement. This was also observed in patients who or crossed over from danazol (Danocrine) to receive momelotinib.

®, Gerds discussed the findings from MOMENTUM, the trajectory of JAK inhibitors for the treatment of myelofibrosis, and whether momelotinib can contribute to the JAK inhibitor momentum; as well as the potential benefit these drugs can offer for patients with myelofibrosis who have anemia.

For patients on the momelotinib-to-momelotinib arm (n = 130), the week 24 symptom responses were sustained through week 48 of treatment in 97% of patients. This occurred in 100% of patients in the danazol-to-momelotinib arm (n = 40).

Additionally, for the patients who did not have a Total Symptom Score (TSS) response to danazol and therefore crossed over to momelotinib at week 24, 29% experienced a TSS at 48 weeks. Also at week 48, 20% of patients who continued momelotinib in the open-label phase from momelotinib in the double-blind phase experienced a TSS.

Early crossover to momelotinib was permitted if disease progression was confirmed. In the open-label crossover phase after 24 weeks of treatment, momelotinib was given at 200 mg daily.


“This study selected patients who had previous JAK inhibitor exposure, were anemic and also significantly symptomatic and had large spleens. It was looking to see if momelotinib was a better option for these patients,” Gerds explained. “Danazol was chosen as a comparator because it is an active agent in remedying anemia in these folks, and momelotinib is a special JAK inhibitor that not only can shrink spleens and improve symptom burden, but it can also have a potential effect on anemia through inhibition of ACVR1.”


“The first key take-home point from the data we presented was that there were no new toxicity or safety signal seen. The data was very consistent [with] what we saw in the original 24-week analysis. This is, of course, incredibly important when you think about the fact that these [patients] might be on this medication for a long time,” he added. “Moreover, the responses were quite durable. Patients who responded at week 24 continue to respond through week 48, whether we’re talking about transfusion independence, spleen volume response or symptom burden improvement.”

An interesting point from the data, according to Gerds, is that patients who did not show an original symptom response during their first 24 weeks of treatment did so during the next 24 weeks, indicating that additional therapy may be beneficial. Moreover, investigators looked at different platelet count cutoffs, and the response rates were similar no matter what the platelet count threshold was for that ad hoc analysis.

“That’s important because thrombocytopenia [can] often co-occur with anemia,” he noted. “So, if you have a drug that treats anemia, you also want [it to] have efficacy in patients who are thrombocytopenic.”

Gerds AT, Mesa RA, Vannucchi AM, et al. Updated results from the Momentum phase 3 study of momelotinib (MMB) versus danazol (DAN) in symptomatic and anemic myelofibrosis (MF) patients previously treated with a JAK inhibitor. 

. 2022;140(suppl 1):1514-1515. doi:10.1182/blood-2022-162783

Videos

Aaron T. Gerds, MD, MS, unpacks data seen with momelotinib for patients with anemic myelofibrosis. 

Aaron Gerds on JAK Inhibitor Therapy for Anemic Patients With Myelofibrosis

Although there is holiday cheer all around us, RNs in oncology still face the reality of burnout and post-traumatic stress disorder (PTSD).

RNs with serious mental illness have been a focus of conversation since Nicole Linton, a travel nurse, was charged with killing 6 people in a horrific car accident.

Nicole Linton is a 37-year-old travel nurse currently in jail in Los Angeles, California.

 She walked out of her job at a major LA hospital and was involved in a horrific car fatality. She was diagnosed with bipolar disorder before her accident and was not on any medication.

Linton is being held on $9 million bond, which was later removed as a possibility. She has been charged with 6 counts of murder and 5 counts of vehicular manslaughter with gross negligence.

 This case highlights the vulnerability of nurses with mental health issues.

Nurses, similar to the general population, are at risk for severe mental health problems. Paying attention the well-being of colleagues, as well as learning to instill self-care practices into daily workflows, are therefore critical for RNs.

Nurses suffer from burnout and PTSD and in fact are at risk for suicidal thoughts and tendencies. PTSD symptoms were identified in 22% of RNs in 2 studies and 18% of those evaluated fit into the parameters of a full-scale PTSD diagnosis.

 Female RNs are more prone to suicide completion than women outside of the health care setting (11.9% vs 7.5%). In addition, male nurses commit suicide more than men in the general population. (39.8 compared with 28.2 per 100,000).

The American Nurses Association (ANA) formed a task force in 2019 to look at the problem of nurse suicide.

The data reveal that the prevalence of mental illness in the health care work force in general is 40% for anxiety, 49% for PTSD, 37% for distress in general, and 37% for rates of depression.

 In so far as suicide compared with female doctors, there is a 70% higher rate in female nurses.

A solution to these mental health problems may be found in the ANA Code of Ethics for Nurses.

 This code states that nurses are obligated to practice self-care in addition to taking care of their patients. This is an international theme. Similar solutions for self-care for RNs are promoted in Japan, Australia, Canada, and the UK.

In addition, Jean Watson’s Theory of Human Caring promotes self-care of the nurse as an essential part of practice.

 It further explains that the nurse be kind to her or himself as well as show oneself compassion. This is necessary to provide the same level of care to patients.

Some other solutions in addition to promoting talking about self-care theories are more practical and include “pizza parties, coffee bars, meditation rooms, and self-care modules.

 Employers need to assess their employee’s mental health care needs. There are 2 groups that are trained to deal with mental health issues in the health care settings. They are mental health nurses and nurse coaches who are board certified.

Nurses advocate for social work and psych consults for their patients in oncology and other settings. When it comes to themselves and mental health, a stigma still exists.

 There may also be a double standard in this scenario. It is acceptable to have a patient with mental illness but a coworker with the same problem may be not treated as well.

The topic of resiliency is the elephant in the room here. Nurses are taught to be resilient, flexible, and adaptable and their superpower is multi-tasking. These attributes though admirable in the nurse universe can backfire. A nurse with a mental illness may fall through the cracks until they have a mental health emergency,

 such as losing a patient, a parent or dog. Other crises could involve going though a divorce or breakup.

 Resiliency is the goal but is a not a solution all the time especially if someone is depressed. Self-care as a solution can be part of an evidence-based plan

Oncology nurses work in a setting that might exacerbate any underlying mental health problems. While getting through a shift may feel like the main goal, self-care and resiliency is equally important for the RN.

Ibrahim S. After A high-profile car crash, Nicole Linton’s family is searching for truth in tragedy. ESSENCE. November 26, 2022. Accessed December 20, 2022. 

Linton M, Koonmen J. Self-care as an ethical obligation for nurses. 

. Published online July 28, 2020. doi:10.1177/0969733020940371

Butler RM. Serious mental illness in healthcare and academia: a lived experience. 

. 2022;29(5):624-629. doi:10.1111/jpm.12862

Articles

Oncology nurses work in a setting that might exacerbate any underlying mental health problems. Although getting through a shift may feel like the main goal, self-care and resiliency is equally important for the RN.


Opinion: Self-Care Is Key to Preserve Mental and Emotional Wellness for Oncology Nurses

Although the frequency of cancer survivorship visits may vary on an individual patient basis, their role in cancer care remains crucial as long-term follow-up often reveals unique complications not seen during active treatment, according to Ellen Miller, MSN, FNP-BC.

Miller, who is a nurse practitioner at Vanderbilt University Medical Center, conducts routine follow-up and survivorship visits in the radiation oncology department. These appointments occur approximately 3 months after the completion of radiation therapy and cover content such as the long-term toxicities associated with treatments, the need for continued routine screenings (such as PAP and mammograms), and other additional resources.

Survivorship visits, however, may be even more nuanced, as patient needs continue to evolve on an individual basis. These visits usually begin a year posttreatment and can, according to Miller, include anything from “discussing the psychosocial ramifications of a cancer diagnosis and treatment to anxiety, fear of recurrence, [or] financial concerns.”

In one instance, Miller encountered a patient who had chosen to pursue pregnancy after electing not to undergo fertility preservation as a teenager. Although Miller herself is not a fertility specialist, she found this patient case interesting, and decided to delve into what fertility and pregnancy conversations between a provider and a patient may need to look like in the survivorship setting.

 Miller discussed this unique patient case, and what her major takeaways from the experience were, highlighting resources that other nurse practitioners working in survivorship clinics might find useful.

A Personal Experience in Survivorship Treatment

In a survivorship visit, Miller met a 26-year-old woman who had undergone treatment at 19 for stage II natural killer/T-cell lymphoma of the nasal cavity.

This patient’s treatment included the SMILE chemotherapy regimen of dexamethasone, methotrexate, ifosfamide, asparaginase, and etoposide plus adjuvant radiation therapy of 50 Gy in 25 fractions. She completed treatment in April of 2017, but in December 2018 and August 2020 was given 4 weekly doses of rituximab (Rituxan) for a rising EBV titer. Miller explained that in this patient’s case, the chemotherapy ifosfamide could have had an impact on fertility.

Although she did not initially treat this patient after therapy, Miller noted that “this patient stated that her health care team discussed fertility preservation with her, but that she declined as she was 19 and thought she would not want to have children, but then as she got into her mid-20s and got married, her thoughts changed.”

Currently, this patient continues in survivorship care and was able to get pregnant without any medical intervention. Her daughter is doing well, and Miller advised her patient to consult with an OB/GYN or a fertility specialist in the future if she wants to pursue additional pregnancies.

According to the Alliance for Fertility Preservation, the standard fertility preservation method for males is sperm banking. Other options included sperm extraction, electroejaculation, and testicular shielding from radiation—however, this is not always possible. Testicular tissue freezing is an experimental method of fertility preservation and includes freezing sperm to use for in vitro fertilization, testicular sperm extraction, and testicular shielding during radiation therapy. Females can freeze embryos (fertilized eggs) or oocytes (unfertilized eggs)—these are considered standard treatments. In certain cases, ovarian tissue may be frozen, and ovarian shielding and ovarian transposition may be options as well. Hormonal treatments for women are currently under investigation.

Radiation therapy, chemotherapy with alkylators and surgery may all effect fertility in males and females. The age of the patient, as well as the dose they receive, can impact the extent to which their fertility is impacted.

Moreover, it can be difficult to assess fertility sometimes, according to Miller, because many treatments can cause temporary infertility. Additionally, certain treatments can cause premature menopause in women (mid to late 30s) and this can be an important factor to consider as well. Because women are born with all the eggs their bodies will produce, when treatments reduce egg supply, ovarian failure is a possibility. Chemotherapy can also severely damage those egg and surgeries such as hysterectomies affect fertility by limiting the ability to carry.

“Not only can chemotherapy damage existing eggs, but it can also lead patients to have early or premature menopause,” Miller emphasized.

Financial Aspects of Fertility Preservation

Unfortunately, cancer care costs may be high and paired with fertility preservation, can be difficult to manage as there are no federal laws requiring insurance companies to cover fertility preservation. States that have passed laws requiring coverage from insurance companies as of September 28, 2022, are California, Utah, Colorado, Illinois, New York, Maine, New Hampshire, Connecticut, New Jersey, Delaware, Maryland, and Rhode Island. Aside from these 12 states, the approximate cost off egg, embryo, and tissue freezing range from $10,000 to $15,000 plus storage fees and sperm banking costs between $500 to $1000 plus storage fees.

“The out-of-pocket [cost] for fertility preservation is $10,000 to $15,000, on average. That’s hard for [anyone], not to mention a young male or female,” Miller said.

Fortunately, this young woman was able to become pregnant naturally; however, the experience caused Miller to reflect on what pregnancy conversations should look like in the survivorship setting.

“[The] trajectory for her experience was standard, and we were thankful for that. But there are some reasons why some women would need further monitoring,” she noted.

For instance, for patients who received anthracycline chemotherapies, or left-sided chest radiation, cardiac monitoring is recommended, as both of these treatments can potentially damage the heart, and pregnancy can make the heart work harder.

“We’ve all probably heard of women who experience cardiomyopathy, even women [in the general population], because carrying a child can make your heart work harder,” Miller noted.

Moreover, certain doses of radiation therapy to the pelvis and abdomen can cause scar tissue and decrease the elasticity that allows the female body to stretch during pregnancy, while radiation therapy to the brain can also effect hormones such as follicle-stimulating hormone and luteinizing hormone. She added that “research indicates that sometimes [radiation] can impact the blood flow to the uterus, which could cause a risk of preterm birth or some of that growth restriction.” Consequently, these are all may be important to monitor in this setting.

But luckily, some research suggests that many women can safely have children after cancer treatment with minimal complications.

“Something I found in doing a little bit of research was a study that included several thousand offspring of female cancer survivors and male cancer survivors who were treated for cancers in their younger years,” she said. “They didn’t have an increased risk of any congenital abnormalities.”

“Another piece of data that I found to be encouraging and helpful was that there was not a higher incidence of cancer in the children that were born of cancer survivors, unless the patient’s tumor was inherited, [such as] 

According to Miller, that data should be really encouraging for survivors, and nurses and nurse practitioners can reassure patients that there is hope for childbearing following cancer. She recommends informing the patients to involve an OB/GYN or fertility specialist if they do choose to pursue pregnancy.

Quick Guide to Fertility Preservation. Triage Cancer. 2022.Accessed November 11, 2022. 

Fertility facts. Leukemia and Lymphoma Society. November 2014. Accessed November 11, 2022. 

State laws and legislation. Alliance for Fertility Preservation. Accessed November 11, 2022. 

https://www.allianceforfertilitypreservation.org/state-legislation/

Signorello LB, Mulvihill JJ, Green DM, et al. Congenital anomalies in the children of cancer survivors: a report from the childhood cancer survivor study. 

. 2012;30(3):239-245. doi:10.1200/JCO.2011.37.2938

Ellen Miller, MSN, FNP-BC, a nurse practitioner who specializes in survivorship care, underscores what conversations surrounding fertility and pregnancy may look like after radiation. 

Survivorship Clinic Visits Hold Answer to Questions About Post-Cancer Pregnancies 

Black mulberry extract was more effective than sodium bicarbonate in significantly decreasing oral mucositis and dry mouth symptoms in patients receiving chemotherapy, according to findings published in the 

 Moreover, the intervention also yielded significant improvements in weight gain compared with controls.

In both the intervention (black mulberry extract) and control (sodium bicarbonate) group, there was a statistically significant decrease in mean scores in an oral assessment guide at 1-, 7-, and 15-days post-intervention (

 = .001). According to the Oral Assessment Guide, the mean scores in the intervention group at days 1-, 7-, and 15- was 1.92 (standard deviation [SD], 0.45; range, 1-3), 1.53 (SD, 0.32; range 1-3), and 1.21 (SD, 0.21; range, 1-3). In the control group, the mean scores at the same follow-up intervals were 2.06 (SD, 0.38; range, 1-3), 1.9 (SD, 0.27; range, 1-3), and 1.77 (SD, 0.76; range, 1-3).

In the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) Late Radiation Morbidity Scoring Schema, the mean scores for dry mouth in the intervention group were 2.18 (SD, 0.5; range, 0-3), 1.31 (SD, 0.71; range, 0-2), and 0.54 (SD, 0.03; range, 0-1) and the mean scores in the control arm were 2.45 (SD, 0.75; range, 0-3), 2.05 (SD, 0.51; range 1-3), and 1.55 (SD, 0.51; range 1-2).

Investigators also determined that the weight gain in was significantly higher on days 7 and 15 among patients receiving the mulberry extract than among patients receiving the sodium bicarbonate. The mean scores in the experimental group, on days 7, and 15, were 65.3 (SD, 8.79), and 66.7 (SD, 7.98), and in the control group, were 68.47 (SD, 12.54), and 68.76 (SD, 12.51).

“Results from this study suggest that black mulberry extract may be effective in preventing or reducing mucositis for patients receiving chemotherapy and may also support weight gain," wrote Tuba Karabey, BSc, MSc, PhD, RN, assistant professor in the Faculty of Health Science at Tokat Gaziosmanpasa University and co-investigators, in the study.

“It is important to educate nurses and raise awareness about the use and importance of black mulberry extract in symptom management for patients with cancer [as] it is believed that recommending black mulberry extract to patients and their families for managing symptoms of oral mucositis and dry mouth, and continuing to apply it when they are discharged, can be effective in symptom control,” study authors added.

Chemotherapeutics agents—which suppress the growth and maturation of cells, disrupting the primary mucosal barrier in the mouth and throat—are often associated with oral mucositis. Oral mucositis can be linked to erythema, edema, bleeding, ulcerations, and hoarseness, as well as difficulty with breathing, chewing, and swallowing. It can also lead to inadequate nutrient intake, malnutrition, and communication problems, as of which can cause negative effects on a patient’s quality of life.

Black mulberry has been investigated in various settings as a management strategy for oral mucositis. The extract contains papiriflavonal A, kuraridin, saforaflavanon D, and saforaiso flavanon A—all of which have demonstrated antifungal and strong antimicrobial activity and are known to be effective in treating mouth and dental wounds. Black mulberry molasses demonstrated efficacy in decreasing oral mucositis in patient undergoing head and neck radiation, and black mulberry syrup reduced the toxicity in patients with obstructive pulmonary disease unrelated to cancer. However, Harman et al, found that black mulberry syrup did not prevent oral mucositis in patients undergoing stem cell transplantation,

 and Sari et al, found that the syrup did not reduce the toxicity in patients receiving head and neck cancer radiation.

The purpose of this study, therefore, was to assess the efficacy of black mulberry extract compared to sodium bicarbonate. In Turkey, where this study was conducted, sodium bicarbonate is one of the most common substances used to prevent mouth sores in patients undergoing chemotherapy (54.2%). Other common substances include chlorhexidine gluconate mouthwashes (68.2%); saltwater (51.7%); sage, chamomile, and fennel tea (46.7%); water with lemon (27.5%); black mulberry molasses (26.7%); honey (24.2%); and turmeric (17.5%).

A sample size of 40 patients were randomly assigned to either the sodium bicarbonate or black mulberry extract group. All patients were inpatients on the oncology unit, 18 years or older, and receiving their first course of treatment with methotrexate chemotherapy. The dose of methotrexate was 3.5 g/m

 of which was administered in 1000 mL 0.9% sodium chloride over 15 minutes, and the remaining 3 g/m

In the control group, nurse researchers applied 10 cc of 8.4% sodium bicarbonate mouthwash for 30 seconds 3 times daily for 15 days. In the intervention group, nurse researchers applied 5 ml of black mulberry extract for 60 seconds 3 times daily for 15 days. The extract contained ripe black mulberry fruit, citric acid, and about 9% fruit sugar. It did not contain glucose or preservatives. Patients were instructed not to consume anything within 15 to 20 minutes of extract application so as to not disturb the mucosal lining. Of note, the extract, which is approved by the Turkish Ministry of Agriculture and Rural Affairs, is not approved for the treatment of oral mucositis in the United States, but can be purchased by US residents through various online retailers, pharmacies, and grocery stores.

Based on the findings, study authors noted that nurses should educate patients about the potential benefits of complementary and nonpharmacologic treatments for symptom management, and to consider black mulberry extract in patients receiving chemotherapy.

Black mulberry extract represents a “cost-effective, evidence-based option to prevent oral mucositis caused by chemotherapy,” study authors concluded.

Karabey T, Karagözogli Ş, Aygün N, Sümer Z. The effect of oral care with black mulberry extract on oral mucositis, dry mouth, and weight gain in patients with cancer. 

. 2022;26(6):636-642. doi:10.1188/22.CJON.636-642

Harman M, Ovayolu N, Ovayolu O. The effect of three different solutions on preventing oral mucositis in cancer patients undergoing stem cell transplantation: a non-randomized controlled trial: a Turkish study - NON-RANDOMISED TRIAL. 

Yuce Sari S, Beduk Esen CS, Yazici G, Yuce D, Cengiz M, Ozyigit G. Do grape and black mulberry molasses have an effect on oral mucositis and quality of life in patients with head and neck cancer? 

. 2022;30(1):327-336. doi:10.1007/s00520-021-06411-6

Black mulberry extract may help patients manage oral mucositis, dry mouth, and weight gain, while receiving oral cancer medications.

Black Mulberry Extract Shows Efficacy in Oral Mucositis Management for Patients Receiving Chemotherapy 

Acupuncture should be recommended for aromatase inhibiter (AI)-related joint pain, according to a panel of experts across the Society of Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO).

Moreover, acupuncture, reflexology, or acupressure may all be recommended for general cancer pain or musculoskeletal pain, and hypnosis may be recommended for those who experience procedural pain. Massage may also be recommended to those experiencing pain during palliative or hospice care.

These recommendations, which were published as part of a guideline update in the 

, note that the quality of evidence is low for mind-body interventions or natural products, and that the body of evidence is insufficient to make integrative medicine recommendations for pediatric patients. Authors also stated that more research is needed to better define the role of integrative medicine interventions throughout the cancer continuum.

“Pain is one of the most common, disabling, and feared symptoms experienced by patients diagnosed with cancer,” the panel wrote in the update. “Integrative medicine, defined as the coordinated use of evidence-based complementary practices and conventional care treatments, includes interventions such as acupuncture, massage, meditation, and yoga, which are increasingly available in cancer centers and are recommended for symptom and pain management.”

According to researchers, an estimated 40% of patients with cancer use integrative medicine on an annual basis. They stressed that these therapies should be used in conjunction with conventional pain management and are not intended to replace these therapies.

A number of well-conducted randomized controlled trials (RCTs) have shown that acupuncture and massage can alleviate pain in patients and survivors, the authors wrote. However, for other interventions, the trials have been small and have lacked methodologic rigor. The panel noted that studies should not only report the statistical significance of their findings, but also the clinically meaningful change in pain severity (a 2-point reduction on a 0 to 10 scale).

The panel consisted of experts in integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, and patient advocacy representatives. They conducted a literature search which included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021, with an emphasis on pain intensity, symptom relief, and adverse events. A total of 227 relevant studies were used to inform this guideline update.

“Since AI-related joint pain affects up to 50% of women on this class of drug and negatively affects quality of life and adherence to hormonal treatment, we recommend that acupuncture should be used for management of this painful condition,” the panel wrote.

 Acupuncture should be offered to patients experiencing AI-related joint pain in breast cancer. (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).

The panel assessed 4 systematic reviews and 5 RCTs in acupuncture and AI-related joint and muscle pain. They determined that the most definitive evidence is from a phase 3 sham-controlled RCT which included 226 patients experiencing moderate to serve AI-related join pain. In 6 weeks, the intervention significantly reduced pain compared with sham acupuncture and standard of care, on a 0 to 10 point numerical rating scale (NRS). More patients receiving acupuncture experience a 2-point pain reduction than those in the sham or waitlist groups (58%, 33%, and 31%, respectively).

 Yoga may be offered to patients experiencing AI-related joint pain in breast cancer. (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).

The yoga recommendation comes from a RCT which assessed a 4-week yoga intervention in 142 breast cancer survivors receiving hormone therapy. Compared with women in the wait-list control, yoga significant reduced body aches (88.0% vs 56.7% with control; 

 = .09). However, in this trial, pain represented the secondary outcome, as the parent trial was designed around insomnia.

General cancer pain or musculoskeletal pain

 Acupuncture may be offered to patients experiencing general pain or musculoskeletal pain from cancer. (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendations: Moderate).

Eight RCTs were used to inform this recommendation. Only one of these had a large sample size (n = 360), where patients were allocated 1:1:1 to receive either electroacupuncture (EA), auricular acupuncture (AA), and wait-list control using usual care prescribed by their physicians. This RCT showed that EA reduced pain by 1.9 points on a 0 to 10 NRS, and AA reduced pain by 1.6 points compared with usual care at the end of treatment. These treatment effects were maintained 6 months post-assignment and were associated with minimal toxicities. Although there was no blinded sham control, the committee determined that acupuncture may be considered for chronic musculoskeletal pain.

 Reflexology or acupressure may be offered to patients experiencing pain during systemic therapy for cancer treatmen.t (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).

Seven RCTs evaluated the efficacy of reflexology, 6 of which showed significantly less pain with the intervention than with controls. Four trials included less than 50 patients per arm, but 3 included more than 90 patients per arm. Controls varied across the trial, and 2 trials blinded patients to group assignments.

Massage may be offered to patients experiencing chronic pain following breast cancer treatment. (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Moderate).

Massage was assessed in 5 randomized trials with a total of 127 patients experiencing chronic musloskeletal pain after breast cancer treatment assessed. Three of these were of high methodologic quality, and 1 was a blind intervention. Controls in the trials included an educational session, physical therapy, or sham control. Massage was shown to have a small to moderate effect in pain reduction, and therefore, massage may be offered to decrease pain intensity in this setting.

Hatha yoga may be offered to patients experiencing pain after treatment for breast or head and neck cancers. (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).

Hatha yoga for musculoskeletal pain was evaluated in 2 RCTs, 1 with patients with head and neck cancer (n = 40) and 1 with patients with breast cancer (n = 42). Both trials had small sample size and follow up was completed at similar intervals. Both trials showed a significant difference in pain severity with the intervention, and pain reduction was maintained at 2.5 months post treatment; however, the small sample and lack of attention controls result in a body of evidence that is considered low.

Guided imagery with progressive muscle relaxation may be offered to patients experiencing general pain from cancer treatment. (Type: Evidence based, benefits and harms not assessable; Evidence quality: Low; Strength of recommendation: Weak).

Four RCTs supported this recommendation. These studies spanned across multiple types of cancer, and 2 included intervention arms that only included 20 participants. The blinding of participants, health professionals, data collectors and data analysts were inconsistent, and there were little safety data.

Chemotherapy-induced peripheral neuropathy

Acupuncture may be offered to patients experiencing chemotherapy-induced peripheral neuropathy from cancer treatment. (Type: Evidence based-informal consensus, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).

This recommendation was informed by 2 systematic reviews and 7 RCTs with small sample sizes. No major toxicities were reported and most demonstrated a benefit of acupuncture for pain reduction in this setting. One phase 2 trial showed a significant reduction in chemotherapy-induced peripheral neuropathy with acupuncture over sham acupuncture. However, the small sample sizes and high or unclear risk of biases limit the evidence.

Reflexology or acupressure may be offered to patients experiencing chemotherapy-induced peripheral neuropathy from cancer treatment. (Type: Evidence based, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak).

Two small RCTS with approximately 30 patients per arm have been conducted to assess reflexology for chemotherapy-induced peripheral neuropathy symptoms, including pain. The first found improvement ins sensory functions, but not pain, while the latter showed lower levels of symptoms, and higher peripheral skin temperature level. Adverse effects were not reported in either study; however, the potential benefits likely outweigh the potential arms, the panel concluded.

Hypnosis may be offered to patients experiencing procedural pain in cancer treatment or diagnostic workups. (Type: Evidence based, benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).

Five studies have evaluated the efficacy of hypnosis in procedures 3 of which demonstrated methodologic weakness and 2 of which were well designed with an attention control as well as at standard of care arm. The 2 most rigorous trials, which included more than 200 randomly assigned participants, demonstrated significantly lower pain ratings compared with control rms with a median reduction of at least 2 points on the 0 to 10 pain point scale. Based on these trials, hypnosis may be recommended to help manage pain. Of note, in these studies, hypnosis was provided throughout the procedure, not just for a short time before the procedure.

Acupuncture or acupressure may be offered to patients undergoing cancer surgery or other cancer-related procedures such as bone marrow biopsy. (Type: Evidence based-informal consensus, benefits outweigh harms; Evidence quality of: Low; Strength of recommendation: Weak).

Investigators assessed 12 RCTS which looked at the effect of acupuncture or acupressure in reducing surgery or procedure-related pain; however, all were limited by small sample size and an unclear or high risk of bias.

Music therapy may be offered to patients experiencing surgical pain from cancer surgery. (Type: Evidence based, benefits outweigh harms; Evidence quality of: Low; Strength of recommendation: Weak).

The investigators looked at 3 studies which showed significant benefit with pain scores with music therapy; however, 2 of the studies were determined to have a high risk of bias, and 1 included a small study sample.

Massage may be offered to patients experiencing pain during palliative and hospice care. (Type: Evidence based; benefits outweigh harms; Evidence quality: Intermediate; Strength of recommendation: Moderate).

Fourteen “low-quality” trials from 2009 showed that there is encouraging evidence that massage can be useful in alleviating pain in this setting. However, a 2020 systematic review showed that 3 RCTs also showed favorable results for massage, including 1 high-quality large multicenter trial with 380 adults with various types of advanced cancer. In this trial, treatment with massage showed an immediate beneficial effect on pain reduction (mean difference, 0.90; 

 < .001) and no adverse events were reported.

Mao JJ, Ismaila N, Bao T, et al. Integrative medicine for pain management in oncology: Society for Integrative Oncology-ASCO guideline. 

. 2022;40(34):3998-4024. doi:10.1200/JCO.22.01357

An ASCO/SIO expert panel outlined evidence supporting integrative therapies for adults. There is insufficient evidence in the pediatric population.

ASCO/SIO Panel Recommends Acupuncture For Adults With Aromatase Inhibitor–Related Joint Pain 

An advanced-practice RN (APRNs) led discharge education and follow-up program reduced the readmission rate for patients with melanoma who were treated with immune checkpoint inhibitor (ICI) therapy. The findings of the program were published in the 

In the pre-initiative setting (n = 32), 11 patients needed to be readmitted because of an ICI-related toxicity. However, post intervention (n = 13), no patients were readmitted because of an ICI-related toxicity.

“Hospital readmissions are negatively associated with health care quality and costs,” Michelle L. Rohlfs, DNP, APRN, FNP-BC, AOCNP, an advanced practice RN at The University of Texas MD Anderson Cancer Center in Houston, wrote in the study. “Because of the nature of the disease and treatments, readmissions are high in patients with cancer, often occurring within the first few weeks of discharge.”

According to Rohlfs, this evidence-based is 1 strategy to reduce unplanned readmissions for patients with immune-mediated treatment toxicities.

The initiative was based out of the Melanoma Medical Oncology department at The University of Texas MD Anderson Cancer Center, where many patients seek treatment for advanced melanoma. According to Rohlfs, many patients will receive ICI therapy, which typically occur in the outpatient setting. If a significant toxicity occurs, then patients will be admitted to the inpatient setting to treatment with high-dose intravenous steroids. To be eligible for discharge, patients need to be able to transition to oral steroids and be able to continue steroid tapering setting. Close monitoring and concise patient education is key throughout this process to safeguard against readmission.

The department had a 30-day readmission rate of 22%, which was above the institutional goal of 10%. Thus, APRNs working in the department developed and implemented a structured patient discharge program to help improve readmission rates for these patients.

A literature review revealed that most hospital readmissions occur within 7 to 10 days of discharge, and that patients who received ICIs are at a greater risk for readmission because of these agents posit a high risk of immune-mediated toxicities. It also showcased that high-quality discharge programs can reduce readmission rates as they improve care transitions, and that nurse-led follow-up telephone call programs have been effective in reducing readmissions.

To that end, APRNs created a teaching program for patients who were admitted to the impatient unit with an immune-mediated toxicity. As per the program, patients received daily education while still in impatient setting regarding their specific toxicity and signs to look out for. Once they were discharged, the APRN followed-up with phone calls on days 3, 6, and 9. Each phone call lasted approximately 30 minutes, and APRNS would use the American Society of Clinical Oncology guidelines to help guide patients thought symptom management over the phone.

The discharge teaching tools included and administration and daily checklist, a day-of-discharge checklist, post-discharge telephone follow-up script.

The administration and daily checklist included the following protocols:

Identify where the patient will return upon discharge.

Instruct the patient or caregiver on the practice of using the whiteboard to write down questions. The care team writes down goals of care.

Distribute special immune-mediated toxicity education to the patient or caregiver (eg, National Comprehensive Cancer Network education).

Give verbal education regarding the patient’s diagnosis.

Identify any homecare needs. Arrangements should be made with the team if needed (eg, physical or occupational therapy, case management, social work).

The day-of-discharge checklist outlined the following protocols:

Distribute the Quality of Discharge Teaching Scale to the patient or caregiver.

Discuss postdischarge follow-up telephone calls.

Medication teaching and reconciliation should be completed the day before or day of discharge.

Review the patient’s condition, including the continuation of care in the outpatient setting and warning signs to monitor after discharge.

If the caregiver is not in the hospital, discuss via telephone and address further questions.

Discuss follow-up appointments with the oncology team and specialty services, if applicable.

If home care is needed, arrange it before the discharge date.

Place all discharge teaching information in the after-visit summary.

Provide contact information for the healthcare team.

Lastly, the post-discharge follow-up script included the following questions:

Do you have any questions regarding your recent hospital stay?

Do you have any questions about how to take your medications?

Do you have any questions about the discharge instructions given to you during the hospitalization?

Do you know when your follow-up visit is with [insert medical oncologist name]?

Were you given a follow-up visit with [insert specialty service]? (if applicable)

Do you have any issues with keeping your follow-up appointments?

Rohlfs noted that the 12-week implementation period was a short period and may not be the breast representative sample. Moreover, the sample size was also small, decreasing the generalization of the findings.

Also, according to the study, APRNs shared that this implementation was time-consuming, as their routine tasks were not decreased. However, as the benefit of the program was clear, study authors suggested timing the calls to occur on days 4 and 10 post discharge and aligning the phone call times to occur during steroid completion.

“This quality improvement initiative illustrates how APRNs can be instrumental in providing high-quality discharge teaching in oncology, which supports institutional and nursing efforts to reduce avoidable readmissions,” Rohlfs concluded.

Rohlfs ML. Decreasing readmission rates in patients with immune-mediated toxicities using an APRN-led discharge teaching program. 

. 2022;26(6):659-663. doi:10.1188/22.CJON.659-663

APRNs developed a discharge program which reduced readmission rates for patients receiving immunotherapy for advanced melanoma. 

APRN-Led Discharge Program Reduces Readmission Rates Following Treatment With Immune Checkpoint Inhibitors 

A nonrestrictive diet did not increase the rate of infection, deaths, poor nutritional outcomes, or acute graft-vs-host disease (GVHD) in patients experiencing neutropenia following stem cell transplant, according to findings from a phase 3 trial which were presented at the 

American Society of Hematology Annual Meeting & Exposition

. Investigators noted that these findings mean a restrictive diet is an unnecessary burden for a patient’s quality of life.

There were no differences between the 2 arms in terms of infections. The number of grade 2 or worse infections that were reported with the protective diet (n = 117) was 72 (65%) which was comparable to the 69 (62%) that were reported with the nonrestrictive diet (n = 113; RR, 1.0; 95% CI, 0.81.3; 

 = .80). The rates of severe infection (defined as grade 3 or higher), fever of undetermined origin, sepsis, and pneumonia, were determined to be balanced by investigators.

Microbiological isolation results showed that, in both arms, the bacteria most frequently isolated at blood and stool culture were enterobacteriaceae and 

. Prophylactic fluroquinolones lowered the bloodstream infection rate (RR, 0.2; 95% CI, 0.001-0.600; 

 = .002) but was not found to prevent severe infections (RR, 1.1; 95% CI, 0.8-1.4; 

In the nonrestrictive diet arm, more patients maintained body weight at 1 month post ASCT than those in the protective diet arm (mean change, –2.7kg vs –3.7 kg; 

 = .04). There were no differences between the 2 arms in terms of use and number of days of parenteral nutrition and serum albumin and body mass index variation.

Moreover, 35% of patients in the nonrestrictive group stated that “diet prescriptions don’t negatively impact my alimentation.” Only 16% of patients in the protective diet group agreed with the same statement (RR, 0.5; 95% CI, 0.3-0.8; 

 = .006), indicating that the nonrestrictive diet correlated to higher patient satisfaction.

Lastly, the incidence of grade 3 or higher acute GVHD was comparable between the 2 arms. In the protective diet arm, 20% of patients experienced this toxicity, compared with 9.5% of patients in the nonrestrictive diet arm (RR, 2.1; 95% CI, 0.5-9.1; 

One death was reported in the nonrestrictive diet arm.

A nonrestrictive diet was found to be noninferior to a protective diet in the post-stem cell transplant setting, suggesting that lifting restrictions may improve patient quality of life. 

Supportive Care

Aaron Gerds on JAK Inhibitor Therapy for Anemic Patients With Myelofibrosis

Opinion: Self-Care Is Key to Preserve Mental and Emotional Wellness for Oncology Nurses

Survivorship Clinic Visits Hold Answer to Questions About Post-Cancer Pregnancies

Black Mulberry Extract Shows Efficacy in Oral Mucositis Management for Patients Receiving Chemotherapy

ASCO/SIO Panel Recommends Acupuncture For Adults With Aromatase Inhibitor–Related Joint Pain

APRN-Led Discharge Program Reduces Readmission Rates Following Treatment With Immune Checkpoint Inhibitors

Phase 3 Data Support Leaving the “Neutrodiet” Behind After Stem Cell Transplant

Patients With HR+ Breast Cancer May Safely Pause Endocrine Therapy to Pursue Pregnancy

Cancer Has No Gender: Challenging Assumptions and Improving Quality of Care for the LGBTQ+ Community

Private Medicare Plans Lead to Worse Oncologic Surgery Outcomes vs Traditional Medicare