Non-small cell lung cancer (NSCLC) can oftentimes be diagnosed at a later stage because there are few signs indicative of cancer when the disease first appears. However, by the time NSCLC becomes locally advanced — meaning it spread to the mediastinal nodes in the center of the chest – patients may start to experience symptoms, leading to their diagnosis, according to Beth Sandy, CRNP.

Standard of care still leaves much to be desired in the second-line setting for these patients. However, immunotherapy may be changing that.

Sandy, a nurse practitioner at the University of Pennsylvania Abramson Cancer Center, recently discussed treatment for locally advanced NSCLC at the 

 School of Nursing Oncology Live, Interactive Webcast.

“Once those lymph nodes get big … you start to have symptoms like shortness of breath,” Sandy said.

Experts are currently debating whether or not it is appropriate to conduct surgery on stage III locally advanced NSCLC, according to Sandy, who noted that the potential survival advantage of surgery could come with more adverse events.

“So it appears the concurrent chemo radiation is the better way to go,” Sandy said. “The median progression-free survival (PFS) is only about 8 to 10 months, meaning that patients often are going to recur in that first year after chemo radiation, if they’re going to recur.”

Sandy outlined 3 common drug regimens given with radiation:

Paclitaxel/carboplatin, given at a low dose once a week

Pemetrexed/carboplatin or cisplatin, given at a full dose every 3 weeks

Etoposide/cisplatin, with etoposide given on days 1 through 5 and cisplatin given on day 1 and day 8, repeating for 28 days

“Paclitaxel and carboplatin is probably the most common, as it’s the easiest to tolerate,” she said. “With pemetrexed and platinum cisplatin or carboplatin, the good thing about that regimen is that it’s full-dose… but it can be more toxic with full-dose chemo. Then, etoposide and cisplatin is kind of a middle-of-the road dose.”

After chemoradiation, there traditionally was no further treatment for patients with locally advanced NSCLC. However, the immunotherapy agent durvalumab (Imfinzi) has been showing benefit.

Findings from a randomized, phase 3 clinical trial (NCT02125461) showed that durvalumab (Imfinzi) improved outcomes in patients with stage III, locally advanced, unresectable NSCLC who have not progressed after 2 or more platinum-based chemotherapy/radiation treatments.

Durvalumab bested placebo in median PFS (16.8 months versus 5.6 months, respectively), as well as 12- (55.9% versus 35.3%) and 18-month PFS (44.2% versus 27.0%).

“With PFS, we had significant improvement [with durvalumab],” Sandy said. “

The immunotherapy agent was better than placebo in overall survival, too. In fact, at the 36-month mark, 57.0% of participants on the durvalumab arm were alive, compared to 43.5% on the placebo arm.

“You can see that there is a significant number of more patients alive at the 3-year mark. This is really exciting,” Sandy said. “Once we get to that 5-year overall survival, we can then look and see not only an overall survival, but also maybe that they’re never relapsing…our cure rates may be improving.”

Sandy B. Lung Cancer: Essentials for Oncology Nurses. Presented at: 

 School of Nursing Oncology Live, Interactive Webcast. July 31-August 1, 2020.

Dennis P. A Global Study to Assess the Effects of MEDI4736 Following Concurrent Chemoradiation in Patients With Stage III Unresectable Non-Small Cell Lung Cancer (PACIFIC). Updated March 19, 2020.

Articles

Locally advanced non-small cell lung cancer traditionally had high relapse rates after initial treatment. Now durvalumab may bring better survival rates to these patients.

Durvalumab Boosts Survival Outcomes in Locally Advanced NSCLC

The advent of CAR T-cell therapy is a “game changer for blood cancers,” according to Kelly Garvin, MA, BSN, RN. However, they do have potentially lethal adverse events (AEs), highlighting the importance of specific training and education for nurses who are administering this treatment.

“CAR T-cell therapy is powerful with impressive success rates, but also with specific dangerous [adverse events] that require trained nursing staff to manage,” Garvin, a nurse at the Moffitt Cancer Center, said in a presentation at the 4

 Annual School of Nursing Oncology Live, Interactive webcast.

There are currently 4 FDA-approved CAR T-cell therapies, all indicated for patients with relapsed or refractory blood cancers: axicabtagene ciloleucel (Yescarta), brexucabtagene autoleucel (Tecartus), tisagenlecleucel (Kymriah), and tocilizumab (Actemra).

The treatments work by extracting blood from a patient and programming their T cells to recognize and attack cancer cells. That process can take 10 to 14 days, according to Garvin.

“While B cells develop a very specialized affinity for specific antigens, T cells are more like professional mercenaries that go after the bad guys. And sometimes, cancer cells develop ways of hiding from the immune system escaping that surveillance,” Garvin said. “But with CAR T-cell therapy, we’re combining the specificity and the affinity of a B cell with the cytotoxic fighting ability of a T cell.”

After patients are infused with the re-engineered T cells, they typically stay in the hospital for 2 weeks or longer, Garvin explained. At this time, it is crucial for nurses to monitor for major AEs, namely cytokine release syndrome and neurotoxicity.

“These can occur quickly while the patient is still inpatient and you’re taking care of them. They occur commonly and can be deadly,” Garvin said. 

Cytokine release syndrome (CRS) commonly occurs about 2 to 3 days after a CAR T-cell infusion, but can happen as early as a few hours after. It is caused when a high amount of cytokines — an immune substance – are released into the bloodstream.

Signs of CRS include fever, chills, and rapid heart rate.

“We take vital signs at least every 4 hours on the floor and more often if we feel like something is brewing,” Garvin said. “And then after you can see that hypoxia and hypotension. [We also] monitor labs every day.”

Severe or life-threatening CRS is treated with tocilizumab, and if that does not work, steroids may also be used.

Neurotoxicity can be any number of AEs originating from the nervous system, including delirium, dysphasia, word searching, encephalopathy, and seizures. The first sign is often a headache, and nurses should also look out for a “blank look” in patients’ eyes, Garvin said.

Garvin told the story of when she realized that a patient she had been treating for 2 weeks was experiencing neurotoxicity. “I walked into [her room] 1 morning and I handed her the pill cup, and she just stared at me like she’d never seen it before,” Garvin said. “She didn’t answer any of my questions; she didn’t look at me, and then she poured her pills down her shirt. That was the first time that [I noticed] that some [neurotoxicity] was beginning to brew.”

Risk factors for neurotoxicity — which usually happens about 4 to 6 days after CAR T-cell infusion – include higher disease burden and concurrent CRS.

Treatment for neurotoxicity is often supportive care and steroids may be administered, if needed. Garvin explained that neurotoxicity and CRS both have treatment guidelines depending on what specific type of CAR T-cell therapy the patient is receiving.

Ultimately, CAR T-cell therapy is a game-changer for blood cancer, but — like every other treatment – is not perfect and comes with risks.

“We do see relapse after treatment, we see death from [adverse events],” Garvin said. “I don’t want to oversell the treatment, but what I saw is that this treatment offers the promise of hope for patients for whom traditional chemotherapy didn’t work, and their prognosis is very poor.”

Garvin, K. CAR-T Therapy: Nursing Considerations. Presented at: 4

 Annual School of Nursing Oncology; July 31-August 1, 2020.

Nurses need to know the potentially life-threatening adverse events of CAR T-cell therapy.

CAR T-Cell Therapy: Promising, But Not Perfect

Despite many exciting advances in recent years, there are still aspects of melanoma treatment that need to be further studied and understood, said Grace Cherry, NP, a nurse practitioner at UCLA Health.

We need more research. Not everyone responds to the treatments. It's a lot better now compared to 10 years ago ... and a lot of our patients are living longer. That's the good news.

However, we still have patients that don't respond. So we need to continue with clinical trials so we can improve that and hopefully find a cure for our patients. Something that was never even thought of for many years for advanced melanoma, but now we're actually seeing patients that are responding and perhaps are even cured. So we want to improve on that.

Another unmet need, I would say, would be to learn more about the [adverse event] profiles of these medications. Some of them can be really toxic as far as immunotherapies. And is there a way that we can predict [adverse events]? Is there a way that we can treat them better so that toxicity doesn't have to stop the patient from getting treatment or doesn't decrease the quality of their life? We definitely need more studies on that too.

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More for Melanoma: Nurse Discusses Unmet Needs

 mutations occurring in about 50% of patients with cutaneous melanoma

, the advent of BRAF/MEK inhibitors for this disease type have drastically improved outcomes in recent years, according to Grace Cherry, NP, MSN, RN, a hematology/oncology nurse practitioner at the Ronald Regan UCLA Medical Center.

Cherry discussed recent exciting advancements in the melanoma field at the 

 is a driver mutation,” Cherry said. “It’s like a light switch that signals cells to constantly grow…When it’s switched on, there’s no stopping that signal. It’s continuing to allow those tumors to grow rapidly. So, when given a BRAF/MEK inhibitor, it’s like turning off that switch.”

There are 3 different categories of BRAF/MEK inhibitors. And while there are some overlapping adverse events (AEs) between them, such as fatigue and nausea, each regimen has common AEs that nurses need to be aware of when treating their patients, according to Cherry. In particular, she noted the following:

dabrafenib (Tafinlar)/trametinib (Mekinist): fever

vemurafenib (Zelboraf)/cobimetinib (Cotellic): rash and photosensitivity

encorafeinb (Braftovi)/binimetinib (Mektovi): nausea

“Nurses are our frontline as far as giving these treatments and also in teaching our patients about side effects and detecting them,” Cherry said.

The first step in managing AEs from BRAF/MEK inhibition is confirming that patients have a 

 mutation. “If [patients] get these drugs and they’re 

 negative, they can have a paradoxical effect and make the tumor grow.”

Patients should then undergo a dermatological exam and an echocardiogram, since there is a small chance that they may have a cardiotoxicity. If the patient is experiencing blurred vision — which is rare – they should be sent to an ophthalmologist to check for ocular toxicity.

All patients experiencing AEs from their BRAF/MEK inhibition treatment should undergo labwork, where clinicians can monitor for elevated levels of liver enzymes, white blood cell counts, and rare AEs. Cherry also said that dose interruptions and dose reductions were very common in the clinical trials leading up to the drugs’ approvals.

“It’s warranted to do a dose reduction so [patients] can continue taking it on a continuous basis and sometimes they may discontinue if [toxicities] are really severe,” Cherry said.

Despite the landmark advances of BRAF/MEK inhibitors — as well as other agents, such as immunotherapy – in melanoma, there is still more work to be done

“Our patients have come a long way, compared to before BRAF/MEK inhibitors and immunotherapy came along, but we have a long way to go,” Cherry said. “Not everybody responds to [these agents] and we need to improve them.”

Cheng, et. al. Molecular testing for BRAF mutations to inform melanoma treatment decisions: a move toward precision medicine. 

. 2018 Jan; 31(1) 24-38. Doi: 10.1038/modpathol.2017.104

Cherry, G. Melanoma: Treatment Updates for 2020. Presented at: 4

 Annual School of Nursing Oncology Live, Interactive Webcast. July 31-August 1, 2020.

“Nurses are our frontline as far as giving these treatments and also in teaching our patients about side effects and detecting them,” Grace Cherry, NP, MSN, RN said.
 

Adverse Event Management for BRAF/MEK Inhibitors in Melanoma

Patients with breast cancer may be apprehensive to come into the clinic for treatment amidst the coronavirus disease 2019 (COVID-19) pandemic. However, others may prefer seeing their treatment team in person.

Ultimately, providers should give patients an active role in choosing what kind of treatment they receive (when possible), and help support them through the process, says Madelaine Kuiper, NP, a nurse practitioner at UCLA Health.

Patients is where we're getting most of the direction from. I have some patients that are very reluctant to come into the clinic, or into the infusion center, despite us having the best screening mechanisms or preventative mechanisms that we can have. You know, if it comes down to really a choice about inpatient or infusion treatment or not, I will go with whatever the patient wants to do, and if that means taking our roles of supporting them, and getting them through that, even if that [means] having to talk to them every couple of days to see how they're doing.

However, we are trying to reassure [them] that if you want to come into the clinic to the infusion room, it's okay we are we have [protective] mechanisms in place. And some patients do prefer that because they feel that they're getting seen that they're being assessed appropriately. And, you know, obviously we are mindful as well as if their white counts are declining, we are using earlier rather than later is a growth factor[based treatments] to try and help support these patients.

Support Patients' Treatment Decisions During COVID-19

When researchers break ethnic groups down into more specific groups and nationalities, more disparities often become apparent. However, there is a number of reasons why this may not be done, explained Chastity Washington, MPH, CHES, director of the Center for Cancer Health Equity at The Ohio State University Comprehensive Cancer Center’s James Cancer Hospital and Solove Research Institute. 

Statisticians are data driven. You have to have a certain sample size or a certain number or number for it to be what's called statistically significant.

And sometimes, [it depends on] the community and the population. So I'm in Ohio, and we may not have a large enough Hispanic population, that when we use those numbers, we can truly from a research standpoint, say anything about it.

But then if you look at it individually, and then you add it collectively across the country, in places where there are other Hispanic populations, larger Hispanic populations, then I think that's when you can start to see these differences and parcel them out.

So I think we are moving towards that. I've been to a few conferences where people are encouraging that. I was on a call earlier this week, where a researcher had done that with the Asian population and started looking at specific Asian groups versus lumping everyone together. We also have to start collecting that.

When researchers break ethnic groups down into more specific groups and nationalities, more disparities often become apparent. However, there is a number of reasons why this may not be done, explained Chastity Washington, MPH, CHES. 

Data Breakdowns May Uncover More Cancer Disparities

Melanoma and lung cancer have been the pioneer when it comes to the use of immune checkpoint blockades. Now, as this type of therapy is used in more malignancies, it is even more crucial for nurses to familiarize themselves — and their patients – with the immune-related adverse events (irAEs) that they can cause.

“All nurses really need to be aware of the potential immune-related toxicities and be able to identify them and know what the standard management is going to be,” said Marianne Davies, DNP, ACNP, AOCNP.

s spoke to Davies, assistant professor or nursing at the Yale School of Nursing, about irAEs.

: What are some common irAEs that nurses should be aware of in their patients receiving immune checkpoint inhibitors? 

The most common ones are dermatologic toxicities. And then also, besides dermatologic toxicities, probably gastrointestinal ones. Those are those are the 2 most common, but there are several other ones. So for dermatologic [AEs] it's rash, and pruritis. For gastrointestinal, [look for] diarrhea or colitis.

But remember, any organ system can be affected. So pneumonitis is one of the more serious, potentially fatal adverse events that can occur.

What advice can you give to oncology nurses when discussing these AEs with patients? How should they make sure that they're presenting information in a way that patients can understand and that patients know what to look out for?

There's a lot of different teaching materials that are available, which can be helpful, but it's important for nurses to be able to describe the distinction between immune related toxicities and ones that might occur with other treatments such as oral targeted therapies or chemotherapy.

Educating patients so they know that typically immune-related adverse events are going to occur a little bit later in the course of their therapy and can occur at any time, even after the discontinuation of the treatment. So we've got to continually be alert to those and monitoring those for patients.

Why is a multidisciplinary team important in treating irAEs? 

That's really critical. Initially, some of the side AEs, especially if they're mild, most oncologists or nurse practitioners are fairly well versed in how to manage those, But if they are more serious or if it's a higher-grade toxicity, then it's really important to work with other sub-specialists who have a speciality in specifically immune related adverse events.

[An example with dermatology AEs would be] identifying really key champions in dermatology that can help manage more aggressive rashes. A gastroenterologist is essential for the risk of pneumonitis. Working with a pulmonologist is going to be really valuable too.

In addition, many facilities now are actually starting their immune related kind of clinic or services. And really beginning to delve a little deeper into trying to understand the whole mechanism, and so working with immunologists and rheumatologists has been really helpful in helping to understand the science of the immune related AEs.

As immunotherapy continues to move into different tumor types, nurses must familiarize themselves – and their patients – with immune-related adverse events.
 

Immune-Related Adverse Events: Know What to Look for and How to Act

While cervical cancer rates are expected to decline thanks to the human papilloma virus (HPV) vaccine, there are still certain groups that have higher a incidence of the disease, and it is crucial for nurses to know the signs of cervical cancer, as well as the treatment modalities once someone is diagnosed.

“The key risk factor for cervical cancer is HPV,” Carolyn Grande, CRNP, AOCNP, a medical oncology nurse practitioner at the Abramson Cancer Center Hospital of the University of Pennsylvania, said in a presentation at the 

 School of Oncology Nursing virtual meeting.

“For most people, the body can clear HPV, but it can be chronic for others — especially those who have higher risk types,” Grande explained.

She noted that cervical cancer risk factors are similar to the risks of sexually transmitted diseases. This includes:

Early age (18 years or younger) engaging in intercourse

Number of sexual partners (5 or more) and exposure to sexually transmitted diseases

Long-term use of oral contraceptives (5 years or longer)

While most annual cancer screenings start at an older age, the American Cancer Society recommends yearly cervical cancer screenings, which are conducted via pap test, to start at age 25, with HPV testing every 5 years.

And while the disease often starts off as asymptomatic, patients may have symptoms once the cancer grows larger. These can include: bleeding after intercourse, between periods, or after menopause; pelvic pain during intercourse; swelling in the legs; hematuria; problems moving bowels or urinating.

Since cervical cancer usually has no early symptoms, it is often diagnosed in later stages, and can be treated with radiation, surgery, and/or chemotherapy.

“In terms of cancer treatment in advanced disease, you will have primary chemo radiation. The volume of radiation would be guided by the amount of nodal involvement. In the absence of nodal disease, pelvic radiation, external beam radiation therapy (EBRT) and concurrent platinum-containing systemic therapies and brachytherapy can be options,” Grande said.

For disease with positive para-aortic and pelvic lymph nodes, cervical cancer is often treated with extended-field EBRT, brachytherapy and concurrent platinum-containing chemotherapy.

Metastatic disease, which, unfortunately, is rarely curable, is usually treated with platinum-containing chemotherapy and palliative EBRT.

When it comes to drugs commonly used to treat cervical cancer, Grande noted the following:

Cisplatin/paclitaxel/bevacizumab (Avastin)

Larotrectinib (for NTRK gene fusion-positive tumors)

Entrectinib (for NTRK gene-positive tumors)

As treatments evolve and more people take the HPV vaccine, cervical cancer statistics are trending toward the right direction.

“Globally, [cervical cancer] is the fourth most common cancer-related death in women. The good news, however, is that the incidence is expected to decline in women who received the HPV vaccine,” Grande said.

Cervical cancer is often diagnosed in the later stages, though incidence of the disease is declining thanks to the HPV vaccine.

Cervical Cancer: Symptoms, Treatments, and Outlooks

Oncology nurses need to look out for the signs of immunotherapy-related pneumonitis in their patients with lung cancer, as they have a higher rate of the adverse event than patients with other cancer types, according to Beth Sandy, MSN, CRNP, a nurse at the Abramson Cancer Center of University of Pennsylvania.

[L]ung cancer patients ... they have a higher rate of pneumonitis than other types of cancer where immunotherapy is utilized. For example, melanoma was the first tumor type where immunotherapy became a mainstay of treatment. But their pneumonitis rates, that pulmonary inflammation from immunotherapy, is really low. It's 1% or less.

[I]n lung cancer, if you look at some of the meta analyses, up to 13% of lung cancer patients can experience pneumonitis from immunotherapy. So that is something really to focus on in lung cancer patients is that inflammation, shortness of breath, that can be induced by immunotherapy.

And then the other [adverse events] are pretty typical that we see across tumor types like the endocrinopathies, the hypothyroidism, the colitis, nephritis and hepatitis are uncommon -- 1% to 3%. But they definitely happen, just [like] these other inflammatory [events] and then the [dermatologic] conditions again, less common in lung cancer, but more common in other tumor types. But something that we see frequently I saw one this week like a very strange kind of skin hypersensitivity almost reaction.

When it comes to immunotherapy-related adverse events, patients with lung cancer tend to have higher rates of pneumonitis than other cancer types, one nurse explains.

Immunotherapy-Related Pneumonitis in Lung Cancer

In order to achieve health equity for patients with cancer, physicians must first understand the root cause of heath disparities, many of which may be invisible. Broadening conversations about health and equity, drawing attention to gaps in care, and prompting urgency on the issues that influence health care are crucial first steps to turn conversation into action.

“When we look at disparities, we often times look at them in the context of race and ethnicity, but looking at further at disparities—removing ethnicity and looking at income, economic status, or education&mdash;you’re going to see that cancer mortality rates are higher in poorer populations,” said Chasity M. Washington, MPH, CHES, during a presentation at the 

4th Annual School of Nursing Oncology virtual meeting

 hosted by Physicians’ Education Resource®, LLC (PER®). “We [need to ask]: What can we do outside of what we are doing in our clinics to help those [patients] break down some of those systemic racisms that have existed for those communities?”

Washington, director of the Center for Cancer Health Equity at The Ohio State University Comprehensive Cancer Center’s James Cancer Hospital and Solove Research Institute, said that a good place to start is by using the available data for good. These data include electronic medical records, cancer registries, and other resources that are available through the American Cancer Society and the Centers for Disease Control and Prevention.

“Use these data to see who is coming through your door, who is in your service area,” Washington said. “Because if your service area is 30% racial or ethnic minorities, but 10% of the patients coming through your door are racial or ethnic minorities, that is not a good thing; that is a disparity. Why are they not coming [to you]? They are [being diagnosed with] cancer, but where are they going? Are they going anywhere?”

A wide range of health risks and outcomes are affected by the patients’ environmental conditions, such as where they live and work, also known as social determinants of health. Five key determinants make up the framework and include economic stability, education, social and community context, health and health care, and neighborhood and built environment. “All [these determinants] play a role in the outcome of someone’s health regardless of race or ethnicity,” Washington said.

Patients with lower socioeconomic status have higher cancer death rates than those with higher socioeconomic status, regardless of race or ethnicity. Coupled with that, however, is the 2017 U.S. Census Bureau data that demonstrated 21% of blacks and 18% of Hispanics/Latinos live below the poverty line, compared with 9% of non-Hispanic whites

Factors playing into the higher cancer mortality rates include access to the continuum of care, education surrounding screening and risk factors, as well as health insurance coverage. For example, 42% of African American women are more likely to die from breast cancer than white women despite having similar incidence rates. The patients within this subgroup often receive a diagnosis at a later stage of disease and experience delays in treatment.

“Once you get the patient in the door, the equity issue is already there because they are coming with a later stage disease,” Washington said. “They got the diagnosis, but they delayed start of treatment because of a fear of other things or access issues. So, really trying to understand who you are serving and what are their barriers and what are the resources, not only within your hospital, but in the community.”

Engagement with patients once they are inside the clinic is another critical avenue to overcoming social determinants of health. “Clinical trials, biobanking, genetic testing, and counseling, all of these things are cutting edge and great for patients. But if you look at the data, people of color and [other] underserved marginalized individuals do not participate at the rate that they should,” Washington noted.

Implicit bias plays a role in the treatment decision-making process for patients with cancer. A 2016 study from Penner et al demonstrated that implicit racial bias was negatively associated with important aspects of conversations between non-black oncologists and black patients. The results included a significant negative association in communication (P < .01) and interaction length (P = .02). Further, patients who interacted with oncologists with higher implicit racial bias perceived their communication as less patient-centered (P = 0.01) and reported having greater difficulty remembering the contents of the conversation (P < .01), a key factor in determining courses of treatment.

“You may be presenting [a patient] with a clinical trial and that is sometimes one of the best options, but if you’re not spending enough time with [that patient] and are not spending enough time to address [the patient’s] questions, then they may be less likely to participate or enroll in that study,” Washington said.

Moving Beyond Equality to Equity and Justice

Fixing the system to offer equal access to health care, requires more than providing the tools to the community. It is a multistep process that includes customizing the tools to address inequality, as well as offering equal access to the tools and opportunities.

“You can give everybody the same tools and resources, but not everybody has the same barriers or the same access; [the tools] don’t always get everybody to that same destination, or if they get there, it’s going to take them a little longer or be a little more difficult,” Washington said.

This process begins by understanding the resources available to patients both in the hospital and the community. As the second highest level of influence on health outcomes, according to the social ecological model, community relies on collaboration between organizations and members of the community to address health disparities and their causes to enact change.

“Just because I live in the same city as you and I can get to the same hospital as you, my job may not let me get off during [clinic hours], or my insurance out-of-pocket expense may be more than yours and I might not be able to budget for that, or I may not have a vehicle to get there and [the hospital] is not on the bus line.” Washington said. “We have to look at those sorts of things and look for opportunities to remove those barriers.”

Adjusting clinic hours, providing assistance such as lay navigators or nurse navigators who can help patients enroll in Medicaid and Medicare, participating in state cancer plans, and using available resources from the American Cancer Society and other organizations are a few places to start, according to Washington. By taking the time to remove the barriers and provide more assistance to patients whose situation may require it, that is what elevates the access to care from equal to equitable.

Leadership at institutions are responsible for creating a culture of equity, according to Washington. “If it does not come from the top down, it is not going to happen,” she said.

Ways for institutions to be proactive about promoting equity includes offering implicit bias training for all members of staff, offering cross-culture training between physicians and nurses, interpreter training, and adding equity measures to the employee evaluation and institutional performance metrics.

1. Washington CM. Achieving cancer health equity for the oncology patient. Presented at: 4th Annual School of Nursing Oncology; July 31-August 1, 2020; virtual.

2. Yedjou CG, Sims JN, Miele L, et al. Health and racial disparity in breast cancer. Adv Exp Med Biol. 2019;1152:31-49. doi:10.1007/978-3-030-20301-6_3

3. Penner LA, Dovidio JF, Gonzalez R, et al. The effects of oncologist implicit racial bias in racially discordant oncology interactions. J Clin Oncol. 2016;34(24):2874-80. doi:10.1200/JCO.2015.66.3658

Annual School of Nursing Oncology