Having honest conversations about treatment choices and adverse events is key for oncology nurses treating patients with ovarian cancer, explained Paula Anastasia, MN, RN, CNS, AOCN.
Anastasia is a gynecologic oncology clinical nurse specialist at Cedars Sinai Medical Center in Los Angeles and a recipient of CURE’s 2019 Ovarian Cancer Heroes award at a March event in Honolulu, held on the eve of the 50th Society of Gynecologic Oncology (SGO) Annual Meeting on Women’s Cancers. During the annual meeting, Anastasia sat down to talk with Oncology Nursing News about treating patients who have the disease.
As an oncology nurse, what are some of the biggest challenges you see on a day-to-day basis for patients with ovarian cancer?
I think in the new healthcare era, there is so much information on the internet, and then their friends, who are not healthcare professionals, are saying “you should do this, this and this,” and then there are a lot of myths out there. But also, with the new research that is still not ready for prime time—for instance, with immunotherapy—patients say “I want immunotherapy!” But it's not FDA-approved and it's not quite ready. But we have all these other treatments.
As for the cost [of treatments], the new term … is, of course, financial toxicity. Just because it might be FDA-approved, especially [in the cases of] some of these oral medications, [does not mean that] patients who have Medicare will be able to afford a drug. So, there are a lot of challenges, and I think [that includes communicating] … overwhelming [amounts of] information and trying to get enough time with patients.
What are some of the challenges on the treatment side?
I think that [a big challenge is providing] education and awareness of how to diagnose ovarian cancer at an early time, so that it is more curable, as opposed to diagnosing somebody at stage 3 or 4. In the big picture of cancer, [ovarian] is not the most common, but it is, unfortunately, one of the most fatal, because it is [typically] diagnosed in the late stages. The reason is that there is not enough information on the signs and symptoms. I think the SGO, the national organization of physicians and advanced practitioners, is trying to educate the practitioners who are going to see women on a more frequent basis, such as the primary care physicians and the gynecologists.
We also have to treat the whole patient: not just the physical, but the emotional. Ovarian cancer, unfortunately, is a chronic disease. These ladies are going to be diagnosed and get into remission, but then, unfortunately, most of these patients will recur. And then it repeats. There's a vulnerability and, for lack of a better term, post-traumatic stress feeling, of just always waiting, even if they are in remission and feeling good — just waiting [to see] when and if it's going to recur again. There is both emotional and physical [involvement] in caring for these incredible and courageous ladies.
Can you discuss the current ovarian cancer standard of care, and what toxicities may come about?
Standard-of-care therapy for ovarian cancer is going to be surgery and chemotherapy. Now, it will depend on the disease burden whether or not the GYN oncologist will do surgery up front followed by chemotherapy, or give chemotherapy first, shrink the tumor, and then after 3 or 4 cycles, go in and surgically debulk. The goal is to remove all of the visible disease at the time of surgery. That's why sometimes they will do neoadjuvant chemotherapy, followed by surgery, followed by more chemotherapy.
But in the standard of care, regardless of the order, the outcome would be remission or complete response, evidenced by normalization of CA-125, clean CT scans, and no evidence of disease on pelvic exams.
The standard chemotherapy is usually a platinum and a taxane. With these agents, what nurses and physicians worry about is lowering of the blood count. There's a risk for infection, but patients don't necessarily feel that. So, we educate them and monitor their blood counts. We talk to them about infection precautions.
What patients most often care about is if they're going to lose their hair. Unfortunately, with a taxane, they will lose their hair. We now have new technologies where perhaps patients can keep their hair by using cold cap devices. If they do lose their hair, it starts to fall out about 2 to 3 weeks after they start chemotherapy, and it begins to grow back about a month or two after they finish chemotherapy. So, it takes about six months when they complete chemotherapy before they have regrown a full head of short, chic hair.
Other side effects patients are concerned about include getting sick and throwing up. Not a lot of nausea is associated with this regimen, which is good. One of the reasons is that we have wonderful anti-nausea medicines. That's where the advanced practice nurses and the nurses come in, because we're the ones who are going to manage this. I think we manage it very effectively. I let patients know that I can help them have good days, but I also need them to tell me when they’re not having a good day. I need them to call me or email me.
Patients will also have fatigue, especially if they're receiving chemotherapy right after surgery, which would be about a month after surgery. Believe it or not, I remind patients that being active will actually help decrease fatigue. Obviously, they don't have to be running marathons, but I want them up and moving around. Even if they had surgery, I need them walking around, expanding the lungs so they don't get pneumonia, decreasing muscle weakness — that type of thing. But also, they have to pace themselves.
Another very common side effect is something called peripheral neuropathy, which is manifested by some numbness and tingling in the fingertips and toes. That's something that's subjective, so we will monitor that, and there are some medications that we can advise patients on. Acupuncture works very well for that, too.
There are a cluster of symptoms that everybody is going to have, but it's really important that we partner with our patients and tell them to talk to us. We're going to educate them, we're going to give them recommendations. But sometimes that's not going to work, so I need patients to talk to me so we can re-evaluate and make another plan.