As the cancer treatment landscape continues to evolve, the role of front-line nurses in clinical trials remains essential, according to Anne Delengowski, RN, MSN, AOCN, CCCTM.

“I don’t know if nurses today can truly appreciate where we’ve come because they were never there, [but] I have had the honor and privilege of being there,” Delengowski, who has been an oncology nurse for 42 years, and is the director of Oncology Nursing Education at Thomas Jefferson University Hospital, said in an interview. “In the past, we had very few cancer drugs, we had minimal second-line therapies which are standard now, we didn’t have targeted therapy or immunotherapy, and we had poor symptom management.” 

Delengowski recently presented at the 2022 Oncology Nursing Society Bridge, highlighting notable improvements spanning the course of her career and the excitement that comes with being a part of a clinical trial from start to finish. In a post-presentation interview with 

®, Delengowski offered a personal perspective into how the field has changed during her career as a frontline nurse.

“When I first started as a cancer nurse, we didn’t have the antiemetics we have today, and it was awful. I did a study back then with a colleague from the school of nursing looking at anticipatory nausea and vomiting because the patients would come in vomiting prior to getting their drugs because they were anticipating it happening, [but] very rarely do you see that anymore. We [also] didn’t have growth factors; we didn’t have the colony stimulators to be able to prevent neutropenic fevers, so patients were hospitalized for most of the course of their disease. Today, all the stuff we talked about here came through clinical trials.”

She also highlighted how pain management strategies have significantly improved.

“I worked a lot in nightshift when I was in graduate school, and we didn’t have sustained release narcotics,” she said. “We used to have to wake people up in the middle of the night to give them pain medicine because if we didn’t their pain would be out of control in the morning. Once again, it was revolutionized that we have PCA [patient-controlled analgesia] pumps now, we have sustained release therapy. The nightmare of seeing patients in pain, you kind of weighed the fact if I didn’t wake them up, they’d be in a lot of pain in the morning and if I did wake them up, I interrupted their sleep, and it wasn’t good.”

Throughout her career, she shared that she has been inspired by the advances that clinical trials have brought about. She noted that patients are living longer, healthier lives, and that clinical trials are allowing providers to achieve “magical things.”

She noted, as an example, the breakthrough findings from Memorial Sloan Kettering Cancer Center where 100% of patients with rectal mismatch repair-deficient locally advanced rectal cancer achieved a complete response with dostarlimab-gxly (Jemperli).

Delengowski shared that, prior to working in clinical trials, she did not understand much about the process or have proper understanding or the extent of the behind-the-scenes work. For example, in her presentation, she explained how clinical trials must receive approval form a multidisciplinary disease group and a facilitation committee, along with a protocol review committee. In addition, there is a site initiation visit which provides the principal investigator and the team with training on all aspects of the trial, prior to its initiation.

Teamwork is also critical and research coordinators who understand the trial have been involved from the inception to guide nurses.

As part of her presentation, Delengowski outlined the different phases of clinical trials. Phase 1 trials are specifically designed to find a safe dose of a novel regimen for humans. This step determines how much a new treatment should be given (ie, oral or intravenous administration), and what the maximum-tolerated dose is.

Delengowski stressed, “A lot of times in phase 1 [trials] we don’t know what the symptoms or outcomes might be, so we need to be cognizant of the fact that anything that happens to that patient we need to document. We need to make sure we do it and we need to follow the protocol to dot the i, cross the t and do it all perfectly because if everyone chooses to do something different than it really doesn't make the trial valuable.”

“I remember giving my very first phase 1 [treatment] and I took a step back thinking ‘You want me to give this to a human being now? It’s the first time a human being has received this drug,’” she said. “I was humbled and wowed at the same time. It was wonderful for all involved, but a little frightening it was for us [as nurses] to administer.”

Phase 2 trials are larger and are designed to determine if the new treatment is effective against a certain cancer, as well as its safety profile. Phase 3 trials compare the new treatment (or new use of a treatment) against the current standard of care.

Across the trial continuum, supporting patients during the trial remains a significant part of the nurse’s role as patients can be overwhelmed throughout treatment. Delengowski highlighted that knowing where to get information for patients and helping to educate them is important for front-line nurses.

“It becomes very exciting when you know you’re part of [clinical trials],” she said. “Some frontline nurses may not exactly understand the value they bring, but [they’re] invaluable; We’re the frontline, we’re the last line, we’re the point where the person gets the medication or the therapy.”

However, phase 3 trials, which are usually randomized, can be difficult for nurses, because patients may not be happy to learn they were randomly assigned to receive the standard of care.

Delengowski explained “It's very hard when you talk up a study and the patient was randomized to standard of care. Often a frontline nurse will be confronted with [patients who say] ‘I signed on thinking I was going to get the new therapy and now I got standard of care drug.’ ”

“What I tell [patients] is in phase 3 studies we don’t know that standard care might be the best therapy. We don’t know and that’s what this is all about. I’ve been involved in phase 3 [trials], where the [experimental drug] was not better than standard of care; it was good, but not as good. It’s just part of the process and once you give that information to the patient, they feel a bit better about it.”

When looking back on all the various phases of clinical trials she has been a part of, Delengowski said it was an exciting feeling to think, “Wow, I was part of that, and we were there when it happened. Some of the trials didn’t come to fruition, but a lot of them did and when you look at that and know that you were part of it, it is so exciting…. As cancer nurses we see the patient go through from diagnosis to hopefully a long life, but in between there’s roadblocks. If they fail first-line therapy and other therapies and go onto a clinical trial, we walk that walk with them. I think that understanding that there is that next step [is important].”

Future steps in improving the clinical trial process include ensuring that inclusivity is a priority and that trials will be brought to the community. Historically, clinical trials have been performed in large academic centers which can be difficult to get to and exploring ways to bring them to patients and working with a community-based staff can be beneficial in making the clinical trials more comfortable for patients.

“[Clinical trials] give that glimmer of hope to someone that there may be other outcomes out there,” Delengowski said. “Even if it’s not something that’s going to be beneficial for that individual, which is not always the case, but it leads to phase 2 and phase 3 [trials] where there seemingly is some hope for a disease process that might not have had a whole lot of other options.”

Delengowski A. Clinical trials on the frontline: the changing landscape of clinical trials nursing. Presented at: ONS Bridge; September 13-15, 2022; virtual.

Cercek A, Lumish MA, Sinopoli JC, et al. Single agent PD-1 blockade as curative-intent treatment in mismatch repair deficient locally advanced rectal cancer. 

. 2022;40(suppl 17):LBA5. doi:10.1200/JCO.2022.40.17_suppl.LBA5

Articles

Anne Delengowski, RN, MSN, AOCN, CCCTM, discusses the evolving role of the oncology nurse in clinical trial research.

Clinical Trials Continue to Propel Field of Oncology with Nurses on The Frontline

Cannabinoids have grown in popularity as a method of symptom and pain management for patients with cancer, making candid communication of care options between nurses and patients critical, according to Karen Hande, PhD, DNP, ANP-BC, CNE, FAANP, ANEF.

“Nurses have a role in guiding their patients and sharing with them the available evidence: which is very limited,” Hande, who recently presented on cannabinoids as part of the 2022 ONS Bridge, said in an interview. “We need to share [information] with them, and monitor, and document their use of cannabis and cannabinoids, similar to any other drug therapies that we would follow and educate our patients or caregivers about.”

, Hande, who practices at Vanderbilt-Ingram Cancer Center and specializes in oncology pain management, discussed the importance of nurses staying up to date on developments surrounding cannabinoids and relevant laws as well.

What is the appeal of cannabinoids for patients with cancer? How have consumer attitudes shifted and how has it become popular?

 It’s [become] a pretty popular option for people because they see it on billboards and they hear other people talking; other patients who may be sitting next to them and saying, “Hey, this is what I’m doing to try to feel better or to improve some sort of symptom.”

When you think about the general public [seeing] a store or a facility selling CBD [cannabidiol], it [may appear] that if they’re selling it, it must be safe, or it must be something that is supported or monitored and why not try it.

You cannot blame any [individual] who has cancer [for] trying to mitigate some sort of symptom. [To many,] it looks like it could be harmless. People are curious and [are] trying to manage unwanted symptoms, so they try it; family members also offer this as a mitigating strategy for their loved ones and try to support them with the best intentions.

How effective is it in managing pain and what information can help guide nurses when talking to patients about if cannabinoids are a good idea?

The utility of cannabis, cannabinoids, or cannabis-based medicines for the treatment of cancer is not demonstrated in any sort of data.

With an acceptable safety profile, cannabis may be useful in managing symptoms related to cancer or its treatment, but further clinical trials have to be conducted to evaluate whether the preclinical antitumor effects translate into benefit for cancer patients. We do not know right now.

Oncology nurses must familiarize themselves with the available database to be able to better advise their patients on the potential uses of this complimentary botanical therapy.

Are there any potential risks associated with cannabinoid use? As a nurse, what risks should you look out for especially because patients are not always forthcoming? What might you proactively talk to them about?

When [individuals] see it being sold, they [tend to] believe that this has been monitored or regulated, but it is not; [whether] it is pure CBD or not is not known.

There have been some trials that have been looking at the profile of CBD and the CBD that is being sold. [One] study has shown that there are several contaminants in the CBD that's being sold. So [patients] are just not sure what they are consuming. 

We have to share that with patients—that we cannot say one way or the other that this is a benefit to them or a certain type of dose or a certain brand because we don’t know. [Manufacturers] can claim what they would like on the label—even though that’s really against the law to claim something that may not be true or evidence based.

As an oncology nurse, how would you recommend responding if a patient expresses interest in trying CBD products?

I would first affirm that, of course, [the patient is] interested.

This is all over the media, people see this on street corners—it looks very appealing. They may have had friends or family or a patient sitting next to them affirm some sort of benefit from a type of treatment of CBD.

I would [have them] affirm that and say, “Yes, I understand completely”. [Patients] are curious and want to understand and find something else that can help them. Don’t make them feel bad about it; I want them to understand this is a common experience for many patients.

[However,] I would say we do not have the evidence to support that this is of benefit. Also, we don’t have the evidence to support that [CBD products] do not have long-term adverse effects. I would say to them: this is what we know, and this is your decision to take this substance or not, but I cannot confirm it.

Would you encourage documenting patient use of cannabinoids—even in states where stigma is strong? How does undocumented patient use affect our understanding of cannabinoids?

I encourage nurses to ask patients to [both] start the dialogue and decrease the stigma.

Again, affirm that we recognize [individuals] are trying this. [We want to ask] are you trying it?; is this something that you're interested in? There is some negativity about taking CBD or cannabidiol [but] it’s not illegal; it's legal to take [CBD].

We want to have that documented because the challenge is if you do a urine drug screen, sometimes THC [tetrahydrocannabinol] can be positive in urine [samples].

This has consequences if you’re giving them opioid treatment and have to do urine drug screens. In some states, an illegal substance such as THC may have negative consequences. I have had a lot of patients who take CBD but do not use THC and their urine drug screen or drug screens are positive. They end up being very concerned because they did not realize that they [would test] positive for THC. I explain to them that the CBD products that they were consuming may have had detectable levels of THC in it—which, therefore, turns their urine positive for marijuana or THC.

It's important to have that data in their chart, so they recognize that there is a possibility of what can happen, but I try not to discourage them or give them stigma about it because then patients aren’t going to tell you anything.

Karen Hande, PhD, DNP, ANP-BC, CNE, FAANP, ANEF, discusses increased patient interest in cannabinoids and how oncology nurses can steer pain management conversations to keep patients informed. 

Interest in Cannabinoids Continues to Grow Among Patients With Cancer

® spoke with Milagros Elia, MA, APRN, ANP-BC, about the role that oncology nurses play in increasing dialogue around climate change. Elia recently presented on climate change as part of the 

. In this episode, she discusses how increases in heat and poor air quality can negatively affect vulnerable populations, and the role nurses play in proactively managing their patients’ health in the context of changing local climates.

Top takeaways from the discussion include:

“We know that climate change is damaging human health today and will have a greater impact in the future. These health consequences will inevitably harm some more than others.” 

“As nurses, we realize that extreme heat can take a toll on the body and increase the risk of heat-related illnesses and hospitalizations.” 

“How do we allow for the continuation of care when we have an area that has been flooded? Or [where] wildfires have been?” 

“[If] you have patients going undergoing chemotherapy, they are extra sensitive to the sun; they need extra [sun] protection, so you tell them about the EPA’s [Environment Protection Agency] UV index application.” 

“You don't need to use the word climate change with [your patients] unless they are open to that conversation. What you need to do is you need to address their symptoms and make the connection to their environment.” 

Episode 27: COVID-19 Pandemic Emphasizes Disparities in Cancer Care

Episode 10: The Year of the Nurses' Voice

Climate Change and Evolving Threats to Public Health: The Oncology Nurse’s Role

Better Research Funding Practices Are Needed to Mitigate Disparities in Cancer Incidence and Mortality

Sunscreen Guide Contains Surprises About Effectiveness

Oncology Nursing News® Publication Features

The Connection Between Lung Cancer and Outdoor Air Pollution

Expert Says Pandemic Put a ‘Lens’ on Health Disparities for People Outside the Medical Field

Climate change and health. World Health Organization. October 30, 2021. Accessed September 22, 2022. 

Elia MR. Climate change and its impact on health. Presented at: ONS Bridge; September 13-15, 2022; virtual.

Nogueira LM, Yabroff KR, Bernstein A. Climate change and cancer. 

. 2020;70(4):239-244. doi:10.3322/caac.21610

Walker RK, Pereira-Morales S, Kerr R, Schenk E. Climate change should be on every nursing research agenda. 

. 2020;47(2):135-144. doi:10.1188/20.ONF.135-144

Butterfield P, Leffers J, Vásquez MD. Nursing’s pivotal role in global climate action. 

 2021;14(373):n1049. doi:10.1136/bmj.n1049. PMCID: PMC8201521.

Man RX, Lack DA, Wyatt CE, Murray V. The effect of natural disasters on cancer care: a systematic review. 

. 2018;19(9):e482-e499. doi:10.1016/S1470-2045(18)30412-1

Turner MC, Andersen ZJ, Baccarelli A, et al. Outdoor air pollution and cancer: an overview of the current evidence and public health recommendations. 

. 2020;10.3322/caac.21632. doi:10.3322/caac.21632

, please consider subscribing to our podcast on Spotify, Google Podcasts, Amazon Music, and many of your other favorite podcast platforms, to get a notification every time a new episode is posted. Please take a moment to rate us!

Thanks again for listening to 

Podcasts

In this episode of The Vitals, Milagros Elia, MA, APRN, ANP-BC, highlights how oncology nurses play a role in ongoing conversations regarding the intersection of climate change and public health. 


Milagros Elia Underscores How Oncology Nursing and Climate Health Are Intertwined 

The rise in popularity of oral anticancer therapy has introduced problems of access and insurance coverage that oncology nurses previously did not have to deal with, according to expert presenters at the 2022 Oncology Nurse Society Bridge. However, many resources are available to nurses, and a key first step is to ask patients how they are faring financially.

“Even though you might not have all the answers right then and there when you’re talking to the patient, don’t shy away from a discussion you can have [about] their finances,” said Mary Anderson, BSN, RN, OCN, an oral oncolytic nurse navigator at Norton Cancer Institute.

Anderson presented alongside Christina Bach, MBE, MSW, LCSW, OSW-C, FAOSW; and Nora Hansen, CPhT, in a presentation titled “Managing Oral Cancer Therapies: What Are Your Tools?” The team highlighted the scope of the problem of financial-related toxicities, best practices for financial toxicity assessment, and resources to help nurses connect their patients to the care they need. 

When assessing patients for the first time, oncology nurses are encouraged to ask the following questions:

Are you able to get to the pharmacy to pick up your medications?

Are you able to get medications delivered to your home?

Other key questions include asking the patient to describe their insurance coverage plan, to highlight any other expenses they are worried may arise during their cancer care (ie, transportation, parking, child care, loss of income), if they are concerned about job loss, if they have had difficulty getting a prescription in the past, if their out-of-pocket expenses are what they expected, and if they are worried about financial toxicity affecting their quality of life.

“I start with making sure that folks understand that I’m not trying to be intrusive or overstep my bounds in asking really personal and private questions that we just don’t [normally talk about],” Anderson said. “I always say; ‘I know this is personal. I know a lot of people don’t want to talk about it. But knowing this information, is going to help me help you. And this is all between the two of us.’”

“We are validating that this is uncomfortable,” she added. “We’re also validating that it’s hard to ask for help—and also giving them permission at any time to say, ‘You know what, I don't want to answer that question.’”

Unfortunately, medical debt represents the number 1 cause of personal bankruptcy in the United States.

 Since 2010, cancer care spending has increased by approximately $175 billion. It is expected to continue to grow and reach $246 billion by 2030.

 Moreover, the average out of pocket expenses per patient increased from $1800 to $2900 per month since 2010.

“We have a major crisis when it comes to medical debt in this country,” Bach, an oncology social worker with OncoLink added. “A lot of that has to do with the way cancer [treatment] has changed a great deal in terms of oral oncolytics.”

“What is available to patients and how they access them is quite different than it was when I started as an oncology social worker in 2000,” she added. “[In 2000,] almost [every patient] was admitted for all their treatment for multiple days, it was covered by their major medical [insurance], and there were very few oral medications available.”

Presenters noted that solutions to help patients are also unfortunately limited: assistance from co-pay foundations are limited to certain diseases, procedures, and availability. In private practice oncology settings, which are often the only geographical option available to patients, charity care is not usually offered.

In addition, the Unites States has historically not regulated drug prices or had a system for drug price negation and a diagnosis of cancer does not equate to automatic approval for disability. Paid family leave varies across states but is generally limited—meaning that job loss (and consequent health insurance loss) is a reality faced by many Americans with cancer.

“Our solutions are limited,” Bach said. “I often feel like my hands are tied. It is very frustrating and also very morally distressing.”

Because of these increasing costs, it is not uncommon for patients to delay or forego treatments because of their financial burden. However, it is documented in the literature that financial toxicity is often linked to poorer outcomes.

Financial hardships often also extend into survivorship; 54% of survivors are between the ages of 18 and 64 years, 42% of whom reported experiencing financial hardships following diagnosis. Debt is most prevalent in populations under the age of 64 years, as well as in Black communities.

Previously, the problem in the United States was that most patients were uninsured. However, in 2022, the problem has become that patients are underinsured.

The speakers noted that it can be difficult for patients and nurses alike to understand the difference between Medicare A, B, and D. They outlined the general difference between plans as part of their presentation:

Medicare Part A is hospital insurance and is often premium-free;

Medicare part B is outpatient medical, and patients must opt in and pay a monthly premium;

Medicare part D is voluntary prescription drug coverage, patient pays premium and co-insurance (deductible and up to 25%);

Medicare part C is known as the “advantage plan;” it is offered by private insurance plans that contract with Medicare, it covers the same services as Medicare A, B, and some drug coverages, and patients choose their provider and plan, such as HMO;

Patients may also have Medicare supplements, which is optional additional coverage for co-insurance and deductibles. 

Insured patients are responsible for paying a premium, a deductible, the copay, the co-insurance, but may be unaware of additional items that are not covered. These may include cancer related needs or services, such as wigs, supplements, lymphedema garments, some durable medical equipment, private duty assistance, and indirect costs, including transportation, parking, child/elder care, loss of income/wages, and caregiving. This represents a heavy financial burden for many, speakers agreed.

The recently approved Inflation Reduction Act is expected to help ease some of the financial toxicity that patients face by capping the amount that a patient is expected to pay per year and lowering premium prices.

 Moreover, the act introduced the concept of price drug negations the consequences of which could be monumental for patients, according to Bach. However, despite the act’s approval, many of the benefits are many years away.

In the meantime, nurses should know that although they play a crucial role in helping connect patients to the resources they need, they are part of a team of players who can help patients navigate the world of insurance. Other professionals who can be leveraged include private brokers, social workers, financial navigators/advocates, state health insurance assistance programs (SHIAPS) counselors, ACA navigation assistance, private brokers. Because there are so many people invested in helping connect patients to help, nurses should not feel alone or intimidated to bring up the conversation: they are not expected to solve the problem, but they can help improve the situation.

The experts also recommend that oncology nurses leverage online resources, such as, 

ONS Guidelines™ to Support Patient Adherence to Oral Anticancer Medications

Cancer Support Community Financial Navigation

Gordon D. 50% of Americans now carry medical debt; a new chronic condition for millions. Forbes. October 13, 2021. Accessed September 26, 2022. 

Abrams HR, Durbin S, Huang CX, et al. Financial toxicity in cancer care: origins, impact, and solutions. 

. 2021;11(11):2043-2054. doi:10.1093/tbm/ibab091

Yabroff KR, Han X, Song W, et al. Association of medical financial hardship and mortality among cancer survivors in the United States. 

. 2022;114(6):863-870. doi:10.1093/jnci/djac044

Fact sheet: the Inflation Reduction Act supports workers and families. News release. The White House. August 19, 2022. Accessed September 26, 2022. 

Mary Anderson, BSN, RN, OCN; and Christina Bach, MBE, MSW, LCSW, OSW-C, FAOSW, discuss approaches to help patients navigate financial toxicity and insurance coverage in the age of oral anticancer drugs. 

Rise of Oral Cancer Drugs Signal Deeper Financial Toxicity Issues for Patients 

According to the World Health Organization, climate change is the single biggest heath threat facing humanity today.

 Unfortunately, the effects will be most keenly felt by vulnerable communities and patients with pre-existing conditions, including patients with cancer, according to Milagros Elia, MA, APRN, ANP-BC. Therefore, climate change is not just a health care issue, but an oncology nursing issue. Oncology nursing professionals need to understand how changes in local climates may affect how they care for their patients.

“For oncology nurses, it’s critical to understand who among our patients are at the greatest risk, and why, what makes them so vulnerable, and through what pathways,” Elia said.

Elia recently presented on the topic of climate change as part of the 2022 Oncology Nursing Society Bridge. After the presentation, 

 met with her to gain a better understand of how the changing climate calls for action from oncology nurses.

As she noted in her presentation, climate events have the potential to disrupt core public health infrastructures and overwhelm health services.

 Health systems are expected to remain at the front line and bear high costs from the growing number of extreme climate events.

Moreover, some of the poorest health systems in the United States are most likely to feel the effects of climate change since they have limited tools or resources to protect themselves. For example, communities such as the Navajo nation, who have limited indoor running water systems, and individuals living in places such as “Cancer Alley” in Louisiana are key examples of populations whose health conditions are directly tied to their local environments.

This also includes patients who live in geographically vulnerable areas, such as places susceptible to flooding, as this can cause issues including contaminated drinking water, food insecurity because of drought, an increase of vector borne diseases, transportation difficulties and consequent barriers to care. She noted oncology nurses should be cognizant of that fact that individuals of color and those who live in low-income communities traditionally experience systematically higher exposures to health threatening climate conditions.

“We are only as strong as our weakest link. In this case, that means the most vulnerable populations,” Elia said. She noted that this includes the very old, the very young, those experiencing treatment-related setbacks, or are at an increased risk of heatstroke or respiratory illness—such as patients with lung cancer or lung metastases.

“How do we allow for the continuation of care when we have an area that has been flooded?” Elia remarked. “Or [where there are] wildfires? Now we have barriers to access: there are trees down or there are [power] lines down. Patients don’t have access to their health care coming in. We don’t have universal structures in place to get around that.”

“In the short to medium term, the health [effects] of climate change are going to be determined [by] how much resilience have already [been] built into the current rate of climate change,” she said. “The effects will increasingly depend on the extent to what action is taken now to reduce emissions and avoid dangerous temperature thresholds and potential irreversible tipping points which we are coming rapidly up against.”

Of specific concern to Elia and other oncology nurse professionals, is the increase of global temperatures, as heat can take lives and affect health in a multitude of ways. Investigators with the National Aeronautics and Space Administration and National Oceanic and Atmospheric Administration have determined that the 10 hottest global years on record have been in the past 2 decades and that the summer of 2022 will be the coolest summer that we will have moving forward. As Elia pointed out, this is an intimidating threat to human health.

“Out of these climate threats, the biggest one we’re dealing with here in the United States and globally, is heat,” she said. “As nurses, we realize that extreme heat can take a toll on the body, and the increase of the risk of heat related illnesses and hospitalizations.”

Heat, when combined in an area with flooding, becomes a breeding ground for vector borne diseases, and mold and fungus entering homes. It also increases the risk of heat-related illnesses and hospitalizations. Moreover, heat waves may put individuals at greater risk of the effects of ultraviolet radiation. Elia noted that science has demonstrated that physical activity is a key factor in cancer prevention and is recommended during treatment, but for patients who live in cement cities with little greenspace, taking advantage of physical activity during heatwaves is challenging.

“Climate change is likely to affect cancer control actions, all along the cancer continuum, from increasing areas of exposure, etiology, and modifying behaviors for prevention and early detection all the way through detection, diagnosis and treatment and survivorship,” Elia summarized.

How can oncology nurses make a difference?

Nurses are the No. 1 trusted profession, and therefore, they are well-positioned to connect the dots for patients and families to help them understand the effect of their local environment, according to Elia.

“Our professional duties require that we assess and address our patients and their symptoms in clinical practice,” she said. “We provide them with resources to meet their needs.”

In her presentation at ONS, she highlighted some climate change scripts that oncology nurses may find useful in talking with their patients.

For example, patients who are socially isolated, are elderly, children, outdoor workers, have chronic comorbidities (ie, obesity, cardiovascular or lung disease, etc), or urban racial minorities with lower socioeconomic resources, may be at an increased risk of heat illness. To these patients and their caregivers, a nurse may say, “We are seeing more hot days every year in our area because of climate change and the heat can be tough for individuals with breathing problems or who are older. Let’s discuss ways to make sure you are prepared (

 and outside earlier in the day), and options for getting a break from the heat if needed.”

Adults with cardiovascular disease and/or chronic pulmonary disease, and children with asthma are vulnerable to air pollution. To these patients and their caregivers, a nurse may say, “Climate change and air pollution are caused by the same thing: burning fossil fuels. Together they make air quality worse, and that can make heart and lung disease worse. Checking air quality and avoiding busy roadways when you go out for exercise can help protect you.”

To those with any underlying cardiovascular condition or respiratory disease is at risk of extreme weather conditions like wildfires. When addressing these patients, a nurse may say,

“Wildfires are becoming more common because of climate change. The smoke and particles can travel many miles and can be dangerous especially for individuals with heart or lung disease. It’s important to check air quality information when there are wildfires. Here is an 

 to help you do that and tips to reduce exposure.”

Elia added that there are multiple free apps to recommend to patients. “If our patients are having increased chronic respiratory symptoms, we can talk to them about governmental apps that have been developed to look at air quality that are free. We always want to empower our patients,” she said. “We give them [those] tools, make that connection for them and empower them to be self-sufficient.”

She noted that climate change is not going to be a conversation that all patients are receptive to; however, it is still the job of the oncology nurse to best equip their patients with the tools which will allow them to manage their health.

“Climate change is not going to be the topic that your patients necessarily are open to talking about,” she said. “It is not your job to sit there and try to convince them that all their new symptoms are because of climate change [or that they] become an advocate. That’s not why we’re here. We are here to support them.”

“You don’t need to use the word climate change with them—unless they’re open to that conversation. What you need to do is you need to address their symptoms and make the connection to their environment. So that it makes sense to them, and then give them the tools to help them deal with those symptoms. We take their lead.”

Climate change and health. World Health Organization. October 30, 2021. Accessed September 22, 2022. 

Butterfield P, Leffers J, Vásquez MD. Nursing’s pivotal role in global climate action. 

 2021;14(373):n1049. doi:10.1136/bmj.n1049. PMCID: PMC8201521.

Milagros Elia, MA, APRN, ANP-BC, discusses ways that nurses can advocate for their patients and help them manage health-related symptoms in the context of changing local environments. 

As the number of transplant patient survivors continue to grow world-wide, providing adequate long-term care for this population has surfaced as a problem, according to Stephany L. Rodriguez, RN, MS, NP. Furthermore, chronic graft-vs-host-disease (cGVHD) continues to present a challenge for patients and there is a score of other later adverse effects which require knowledgeable follow-up care as well.

“Transplant survivors have unique long-term health needs requiring knowledgeable follow-up care,” Rodriguez said, in a presentation during the 2022 Oncology Nursing Society Bridge. “Multidisciplinary and multispecialty collaboration remains critical.”

Rodriguez is a nurse practitioner at the University of California San Francisco. In her presentation at the ONS Bridge, “Survivorship After Stem Cell Transplant: Chronic Graft-vs-Host-Disease and Long-Term Follow-up Care,” she said, “Nobody tells patients what could possibly happen, they [often] have no idea how bad or how hard this could be.”

What Is Hematopoietic Stem Cell Transplant?

Hematopoietic stem cell transplant (HCT) is a procedure in which a patient receives healthy stem cells to replace damaged stem cells. Prior to undergoing HCT, a patient will receive conditioning treatment. Conditioning treatment may include high doses of chemotherapy, and sometimes radiation therapy, to prepare the body for transplantation. Following transplant, the new stem cells will travel to the bone marrow and begin the process of forming new, healthy blood cells (including white blood cells, red blood cells, and platelets). This process is called engraftment.

There are 2 types of transplantation that a patient may receive. The first is autologous transplantation, which uses a patient’s own cells to replace damaged cells after high intensity chemotherapy. This method relies on chemosensitivity. Patients who are most likely to receive this type of transplant include patients with myeloma, non-Hodgkin’s lymphoma, and Hodgkin’s lymphoma.

Patients may also receive allogeneic transplantation, which uses stem cells from a matching donor. These donated cells suppress the disease and restore the patient’s immune system. Patients who are most likely to undergo allogeneic transplantation include those with acute leukemia, myelodysplastic syndromes, myeloproliferative neoplasms, chronic myeloid leukemia, and chronic lymphocytic leukemia bone marrow failure disorders.

Long-Term Follow-Up of Transplant Survivors

According to Rodriguez, there is good news when it comes to transplant: there are now more stem cell transplant survivors than ever before. Further, with more than 60,000 HCTs performed annually, there is the potential for there to be more than 500,000 HCT survivors by 2030.

The challenge, therefore, remains in providing optimal care to survivors, both in transplant centers, and throughout community care. Late effects of transplant can affect morbidity, mortality, working status, and quality of life. Unfortunately, the life expectancy for 5-year transplant survivors is approximately 30% lower than the general population.

 In addition, nearly80% of survivors will have or more late effect at 5 years post-transplant.

Many nurses may be familiar with GVHD for patients undergoing transplant; however, according to Rodriquez, there are a host of later effects that many patients are not prepared for.

These key later-effects can range from infections, secondary cancer, heart, and pulmonary problems and extend across endocrine and metabolic issues, bone health complications, sexuality or infertility issues, iron overload, “chemo-brain”, fatigue, cramps, sleep disturbances, as well as mental and emotional effects.

The rate of late fatal infections at 2 years after transplant are 55% for bacterial infections, 18% for fungal, 16% for viral, and 11% for multiple (

In terms of prevention, prophylaxis may be appropriate. Treatment options include include the following: antifungals (Azoles), antivirals (acyclovir), trimethoprim/sulfamethoxazole (Bactrim), atovaquone, dapsone, and antibacterial agents such as penicillin or evusheld. Rodriquez noted that there may be some questions regarding when to start vaccinations in the setting of transplant. COVID-19 and influenza vaccination should begin at 3 months, and other routine vaccinations may start at 6 months.

Undergoing transplant can also increase the risk of secondary malignancies. Patients undergoing HCST are a 3-fold higher risk of another cancer.4 Patients should keep routine cancer screenings to monitor any potential secondary malignancies.

Unfortunately, approximately 20% of transplant survivors will develop osteoporosis after 2 years. They are also at risk of compression fractures, especially in their spine or hip. Women are at greater risk than men. Additional risk factors include age, vitamin D insufficiency, GVHD, low sex hormones, and a sedentary lifestyle.

To help survivors maintain long-term bone health, they should be screened for their vitamin D levels and bone density. If concerns about a patient’s bone health should arise, the patient should be encouraged towards exercise, calcium and vitamin D supplements, bisphosphonates, and hormone replacement therapy.

Another possible complication is severe avascular necrosis. Risk factors may include steroids use and radiation and can be detected through an MRI. Treatment options include orthopedics. Patient undergoing transplant should be monitored for severe pain and join fractures, in particular at the hips and knees.

Many patients will experience fatigue. Paradoxically, exercise represents one of the best remedies to chronic fatigue, Rodriguez noted. However, strategic naps, reduced workloads, and treatments for underlying medical causes and pain are also important.

Other treatment strategies for general health issues include cognitive behavior therapy and sleep hygiene can be effective for sleep disturbances. Hydration and tonic water can help with cramping. For liver toxicities, patients should be advised to avoid alcohol and improve diet and exercise. Phlebotomy may be necessary for iron overload, and physical therapy or foot care can help with symptoms of neuropathy.

Patients are also at an increased of developing kidney problems; they should have their urine proteins periodically checked. They will require annual eye exams to screen for premature cataracts and dry eye syndrome (which can be managed with eyedrops and sunglasses). They will need to have regular dental exams and to understand that they may develop dry mouth and cavities, which may lead to later complications.

In addition, transplant may result in endocrine complications, such as low thyroid or diabetes, and mental health challenges. Patients may also experience brain fog and face short-term memory loss, slow thinking, word-finding difficulty, impaired learning, and executive function. It can take up to 5 years for these symptoms to improve, and patients may require cognitive rehabilitation, methylphenidate, and modafinil. 

Rodriguez SL. Survivorship after stem cell transplant chronic graft vs host disease and long-term follow-up. Presented at: ONS Bridge; Sept 13-15, 2022; Virtual.

Martin PJ, Counts GW Jr, Appelbaum FR, et al. Life expectancy in patients surviving more than 5 years after hematopoietic cell transplantation. 

. 2010;28(6):1011-1016. doi:10.1200/JCO.2009.25.6693

Norkin M, Shaw BE, Brazauskas R, et al. Characteristics of late fatal infections after allogeneic hematopoietic cell transplantation. 

. 2019;25(2):362-368. doi:10.1016/j.bbmt.2018.09.031

Kolb HJ, Socié G, Duell T, et al. Malignant neoplasms in long-term survivors of bone marrow transplantation. Late Effects Working Party of the European Cooperative Group for Blood and Marrow Transplantation and the European Late Effect Project Group. 

. 1999;131(10):738-744. doi:10.7326/0003-4819-131-10-199911160

In a presentation at the 2022 Oncology Nursing Society Bridge, Stephany L. Rodriguez, RN, MS, NP, discussed the later effects associated with hematopoietic stem cell transplant and how to manage them. 

Oncology Nurses Must Understand the Later Effects of HSCT To Provide Adequate Survivorship Care

As more biomarker-directed therapies enter the treatment landscape for various tumor types, education on testing and toxicity profiles of new classes of drugs are needed for oncology nurses, according to Kristin Daly, MSN, ANP-BC, AOCNP. In a presentation at ONS Bridge, Daly presented on the challenges expanding tumor variants pose, new terminology to understand and convey to patients, and how to integrate new testing methodologies into clinical practice.

“Biomarker-driven therapy and biomarker-driven clinical trials are only going to increase because we are getting more and more refined by targeting these treatments [and by] targeting these variants we are able to give patients more effective and focused treatments,” Daly said.

®, Daly, a nurse practitioner specializing in head and neck cancer at Siteman Cancer Center in Washington University School of Medicine in St Louis, discussed the importance of keeping lines of communication open with patients especially as treatment options continue to expand.

 Why is biomarker testing important and which patient populations are having their treatment options drastically expanded by the identification of actionable targets?

 Potentially all patients, [because] it’s growing week to week. My presentation [at ONS Bridge] was on biomarkers [and] I like to point out that biomarkers aren’t really new they’re just a growing class, it’s an inclusive term. Things that we already think about, ER [estrogen receptor]/PR [progesterone receptor] positivity, HER2, RET, those are all biomarkers. Now we have targeted therapies for a number of biomarkers, but we also have a number of [ongoing] clinical trials. There are plenty of things in the pipeline for a variety of cancers.

Kristin Daly, MSN, ANP-BC, AOCNP, discusses the clinical significance of tumor variants and how they are changing the direction of cancer care. 

ONS Bridge

Clinical Trials Continue to Propel Field of Oncology with Nurses on The Frontline

Interest in Cannabinoids Continues to Grow Among Patients With Cancer

Milagros Elia Underscores How Oncology Nursing and Climate Health Are Intertwined

Rise of Oral Cancer Drugs Signal Deeper Financial Toxicity Issues for Patients

Climate Change and Evolving Threats to Public Health: The Oncology Nurse’s Role

Oncology Nurses Must Understand the Later Effects of HSCT To Provide Adequate Survivorship Care

Daly Discusses Biomarkers and Emerging Targeted Therapies for Cancer Care

Oncology Nurses: What Cannabinoid Is Your Patient Taking?

How Oncology Nurses Can Build Their Own Resilience

Patient Education Key in Managing Immune-Related Adverse Events