	Oncology nurses are in the unique position of intimately getting to know cancer patients, and their families, during a crisis and over a prolonged period of time. As a result, the relationships forged are based on deep-seated trust and respect. This bond allows many patients to share their deepest fears with their oncology nurses: â€œWill I die of my cancer? Will I lose part of my body? Will I be able to get through chemotherapy?â€ And perhaps the darkest and most frightening, â€œDoes this mean my children will get cancer?â€ The oncology nurse can play a critical role in helping patients and their entire families find the answer to these questions.

	Approximately 90% of cancer is not hereditary, meaning it is not caused by a single gene mutation. However, as we learn more about genetics and our testing techniques advance to include hundreds of genes, we may learn that a greater proportion of all cancer is at least in part due to inherited genetic changes. Learning how to recognize which patients in your practice are at greatest risk and require a referral to cancer genetic counseling and testing will be a critical way in which oncology nurses can contribute to the field of cancer genetics.

			Table 1. Risk Factors for Hereditary Breast and Ovarian Cancer

		Refer to genetic counseling if the patient has a personal and/or family history of:

		Breast cancer diagnosed before the age of 45

		Multiple cases of breast cancer, pancreatic cancer, or ovarian cancer on the same side of the family

		Even one case of ovarian cancer in a family with breast cancer

		The combination of breast, ovarian, and/or pancreatic cancer in one bloodline

		The combination of breast, ovarian, and/or pancreatic cancer in a single individual (eg, an individual diagnosed with both breast and ovarian or breast and pancreatic cancer)

		Jewish ancestry in combination with any of the above

		Jewish ancestry and one case of breast (at any age), pancreatic, or ovarian cancer (even in the absence of additional family history)

		Known genetic mutation in the family (eg,

		In addition, medullary breast cancer and triple negative breast cancer are over-represented in women with hereditary breast and ovarian cancer

Which of My Patients Are at Increased Risk for Hereditary Breast or Ovarian Cancer?

	A personal history of early-onset, medullary, or triple-negative breast cancer alone means that your patient is at increased risk for a hereditary form of cancer. This simple list of risk factors can steer your referrals for genetic counseling and testing (

	In the frenzy of a cancer finding, imaging, a biopsy, surgery, and treatment, the risk of a hereditary cancer can get lost in the mix. Yet, this piece of information is often essential in surgical and radiation decision making. For this reason, patients at increased risk should be offered genetic counseling and testing before having surgery and radiation, whenever possible.

	Patients at high risk for hereditary cancer who were diagnosed with their cancers >10 years ago and were not referred for genetic counseling are still at risk. This information can help prevent a new primary cancer and help to protect family members from developing cancer. These patients should be referred for genetic counseling, even decades after a diagnosis. The oncology nurse can be crucial in â€œconnecting these dots.â€

			Table 2. Dispelling Myths About Genetic Counseling and Testing

 Breast and ovarian cancer can only be inherited from your mother.

 We can inherit these mutations from either parent with equal frequency. We can pass these mutations on to sons and daughters with equal frequency.		

 Genetic counseling and testing is not covered by health insurance.

 Most health insurance companies cover these services for patients at high risk.		

 My health insurance company will discriminate against me and my family if I have genetic testing.

 We have laws, such as the Genetic Information Nondiscrimination Act (GINA), protecting against this form of discrimination. Violations have not been widely reported in the past 15 years.		

 I've already had cancer, so testing can't help me.

 This information can help patients avoid a second primary cancer and can be critical to other family members.		

 I'm the only one in my family who has had cancer, so it is not hereditary.

 Even if one person has any of the risk factors listed in Table 1, she is at significantly increased risk for a hereditary form of cancer.		

 I don't need genetic counseling. I just want the blood test.

 One of the greatest risks of genetic testing is the risk that the wrong test will be ordered, or that the result will be misinterpreted. Every patient needs genetic counseling by a qualified provider, both before and after testing.

	Many patientsâ€”and cliniciansâ€”have widespread misconceptions about genetic testing that prevent them from seeking care. The oncology nurse can help to dispel these myths (

	The field of genetic testing is expanding rapidly, and more and more patients are now candidates for testing. This testing will guide surveillance, risk reduction, management, and surgical and radiation decision making as we move forward. The oncology nurse will play a key role in finding patients who need genetic counseling and testing, dispelling myths about this field, and facilitating referrals to genetics professionals.

	Ellen T. Matloff, MS, CGC, is a certified genetic counselor and director of Cancer Genetic Counseling at Yale Cancer Center, New Haven, Connecticut.

Articles

Genetic Counseling

Detecting hereditary cancer and providing genetic counseling can help prevent a new primary cancer and may also help to protect family members from developing cancer.

Hereditary Breast and Ovarian Cancer: Which Patients Are at High Risk?

	In summer 2008, Roman Catholic parish priest Father Arthur Humphrey presented with a hemorrhagic pigmented lesion on his back. Three months after the lesion was removed, he developed right arm lymphadenopathy and underwent surgical resection followed by interferon therapy (Kirkwood regimen) for one year.

	Two years after his initial diagnosis and six months after completion of his chemotherapy, Father Humphrey was referred to the John Theurer Cancer Center in Hackensack, New Jersey. When imaging studies revealed further metastasis, this time to the lung and brain, he underwent exploratory right thoracoscopy, right thoracotomy, and a superior segmentectomy. In March 2011 he began a combined regimen of oral thalidomide (Thalomid), oral temozolomide (Temodar), and IV docetaxel (Taxotere).

	After his first cycle of chemotherapy, Father Humphrey developed neutropenia. He was treated with filgrastim (Neupogen) and monitored closely, and continued with the regimen with no subsequent issues. However, in May 2011, computed tomography of the chest, abdomen, and pelvis revealed progressive disease, and the decision was made to switch him to the immunotherapeutic agent Yervoy (ipilimumab; IV infusion [3 mg/kg] every 21 days for 4 cycles), which had just been approved for the treatment of metastatic melanoma. He tolerated the treatment well despite experiencing an atypical immune response/reaction after his fourth infusion, and has subsequently been able to undergo two maintenance treatments with Yervoy.

	In June 2011, an MRI revealed multiple intercranial brain metastases, and Father Humphrey was started on whole-brain radiation. It was also during this regimen that Father Humphrey fell and fractured his right ankle. His ankle was casted and he was confined to a wheelchair until undergoing surgical repair with insertion of a plate and screws.

	As of spring 2012, Father Humphrey is showing a promising response to Yervoy. He is currently seen for blood work every two weeks, and will be followed with imaging studies every six months (more frequently if he becomes symptomatic) while continuing to receive Yervoy maintenance treatments every three months per patient tolerability and physician’s orders.

	Melinda S. Weber, RN, MS, APN, AONC, C-APN, manager, John Theurer Cancer Center, helped prepare, educate, and support Father Humphrey throughout his treatments.

	Weber recalled that Father Humphrey tolerated the thalidomide/ temozolomide/docetaxel combination well, despite the transient neutropenia, noting only that the treatment caused fatigue. “The oral medications are taken at bedtime because of their tendency to cause fatigue, and the temozolomide typically causes nausea,” said Weber. She also noted that some patients undergoing this regimen experience docetaxel infusion reactions, which can be quite overwhelming. To avert such reactions, patients are pretreated with oral dexamethasone (Decadron). The nursing staff also careful to prepare patients for the possibility of such reactions.

	Father Humphrey’s ankle injury was a source of concern. “We needed to make sure that nothing about his ankle fracture, surgery, or the healing process would in any way interfere with the treatment. This was especially important as it related to the ipilimumab, which is such a new drug,” Weber said. She contacted medical experts and was assured that nothing with the injury or its treatment would pose any such problems.

	Father Humphrey described his Yervoy treatment as “very tiring,” recalling the difficulty breathing, swollen eyes, and abdominal rash that accompanied the immune reaction that occurred during his fourth infusion. Treatment with diphenhydramine (Benadryl) and hydrocortisone halted the reaction, but Father Humphrey was unable to continue with his final infusion. He was, however, able to undergo his planned maintenance treatments.

	This reaction notwithstanding, Weber noted that Father Humphrey has actually tolerated the Yervoy treatment quite well. He hasn’t experienced any of the serious immune-related effects associated with Yervoy, including immune-mediated enterocolitis, which can result in life-threatening diarrhea.

	Other potential adverse effects include immunemediated ocular manifestations, dermatitis, neuropathies, hepatitis, and endocrinopathy issues, all of which necessitate continual medical assessment and possible interventions, as well as a battery of blood work obtained prior to each infusion to assess for potential complications. Weber explained that symptoms—such as fatigue, headache, and changes in mental status&mdash;can sometimes be vague. “We grade all toxicities that occur and treat affected patients immediately as appropriate and continue to monitor them closely.”

	She noted that there is a “flip side” to these potentially dangerous toxicity profile. “When patients experience adverse effects from conventional chemotherapy, symptoms are treated but we essentially need to let them run their course until the nadir has passed and healing and resolution has occurred. On the other hand, Yervoy’s immune-related toxicities yield rapid resolution of symptoms because even the serious adverse effects of the drug can be reversed relatively quickly with the appropriate prednisone dosing and medical monitoring.”

	Father Humphrey said the Yervoy treatment appears to be working and has few complaints, other than some itching “underneath the skin” and some difficulty with the twice-monthly blood draws, which have been painful. He realizes that he’s fortunate to be receiving Yervoy “boosters,” which are not currently FDA-approved. Weber explained that Yervoy is currently approved for only four cycles of treatment, but that anecdotal evidence and scientific rationale has led some experts to believe that maintenance “boosters” given every 3 months will improve long-term survival.

Laura Bruck is a freelance writer and editor based in Cleveland, Ohio. She has specialized in healthcare reporting since 1987.

Patient Focus

After a long fight with melanoma, the Roman Catholic parish priest Father Arthur Humphrey was able to receive the immunotherapeutic agent Yervoy, which greatly improved his prognosis. 

Metastatic Melanoma: Timely Approval of Yervoy

	At the 2012 NCCN annual meeting, a panel of oncology nurses discussed the essential components of healthcare for survivors, challenges survivors face, and survivorship program models.

	“An individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life,” said Fran Zandstra, RN, MBA, OCN, director of the Cancer Survivorship Program at the University of Texas MD Anderson Cancer Center in Houston. “Survivorship care…must be tailored to each person’s tumor, treatment, and health history,” Zandstra added.

	According to Zandstra, the four essential components of survivorship care include surveillance for the detection and treatment of late malignancy recurrence; prevention for behavioral lifestyle changes to reduce risk/prevent cancer; intervention for consequences of cancer and its treatment, including medical and psychosocial effects; and coordination between specialists and primary care providers to meet all of a survivor’s healthcare needs.

		Joanne Lester, PhD, CRNP, ANPBC, AOCN®

	Survivorship presents a multitude of challenges, according to Joanne Lester, PhD, CRNP, ANPBC, AOCN®, a research scientist and oncology nurse practitioner at the The Ohio State University Comprehensive Cancer Center in Columbus. Physical challenges include pain, discomfort, cognitive changes, skin and mucosal changes, bone health, neuropathies, cardiopulmonary challenges, fatigue, sleep-wake disturbances, gastrointestinal and genitourinary symptoms, sexuality and reproductive issues, and lymphedema.

	Psychological challenges include anxiety, posttraumatic stress, substance abuse, depression, suicide, spirituality questions, and end-of-life transition.

	Practical challenges include personalization of information and care, economic burden, employment, and family-related issues.

	Mary S. McCabe, RN, MA, director of the Cancer Survivorship Initiative at Memorial Sloan-Kettering Cancer Center in New York City, finished the discussion by describing survivorship program models.

	A multidisciplinary clinic allows patients to be seen by different providers during one clinic visit and provides a comprehensive approach to survivorship, but the program may be difficult to coordinate and reimbursement for all providers is a challenge.

	On the other hand, a disease- or treatmentspecific clinic, one that focuses on one specific disease category or intervention, allows for a focused scope of practice. However, this approach may exclude survivors with the greatest needs.

	Other cancer survivorship program models include a consultative service that covers general survivorship care and an integrated care model that involves embedding survivorship into the oncology clinic as part of the function of the treatment team.

	In establishing a survivorship program, nurses should determine what type of model might work within their institution, establish simple metrics, get support from leadership and peers, understand what needs to be implemented, and be willing to revise.

Conference Highlights

At the 2012 NCCN annual meeting, a panel of oncology nurses discussed the essential components of healthcare for survivors, challenges survivors face, and survivorship program models.

Essential Components of Survivorship Care

	Although oral treatments have revolutionized cancer care, their use presents challenges to both patients and providers. Peg Esper, MSN, RN, AOCN®, ANPBC, an adjunct clinical instructor at the University of Michigan Comprehensive Cancer Center in Ann Arbor, discussed the management of oral oncolytic treatment at the 2012 NCCN Annual Meeting.

	Oral agents provide a variety of benefits versus standard infusion chemotherapy. For patients, self-administering treatment is empowering and the reduction in clinic visits is less disruptive on their career and personal life. For providers, oral treatments offer greater flexibility to modify or stop treatment during a cycle in order to control side effects. These benefits are mitigated by several challenges, including financial strain, patient education challenges, patient compliance issues, and toxicity management.

	According to Esper, the high cost of oral oncology agents is a problem for many patients who either have issues with coverage or steep copays. Additionally, many patients have to deal with the Medicare Part D coverage gap or “donut hole.” While some states have laws requiring equal coverage for intravenous and oral agents, most states lack such policies. To address these financial issues, most oral drug manufacturers offer patient-assistance programs.

	Oral oncology agents also create educational challenges, as patients must fully comprehend how to administer and manage their own treatment. Each agent has unique side effects that need to be monitored, and patients need to know when it is necessary to call their healthcare provider or seek emergency care.

	Even with comprehensive patient education, other issues interfere with successful management of oral agent toxicities. The reduction in clinical visits affords less time to monitor patients. This means an enhanced reliance on patient reporting, which is often incomplete regarding toxicities experienced between cycles of therapy. According to Esper, there are also logistical issues in the clinical setting. Some of the nursing staff may not see patients given prescriptions for oral agents during a clinic visit. Additionally, patient education visits may not be scheduled before treatment begins.

	Relying on patients to self-deliver care also creates adherence issues with oral oncolytics. Some of the factors that impact adherence include cognitive issues, depression, lack of support, a lack of belief in treatment value, and financial concerns. According to Esper, “over-adherence” is just as problematic as “under-adherence,” as some patients think higher doses will enhance and quicken the treatment.

	Esper recommended several strategies for improving treatment with oral agents, including increasing clinical visits at the start of treatment, offering phone support, prescribing no more than one cycle of therapy, advising patients to keep diaries or logs, and providing educational materials for symptom management strategies.

Although oral treatments have revolutionized cancer care, their use presents challenges to both patients and providers.

Challenges With Managing Oral Cancer Treatments

	Cancer pain management has greatly improved with advances in oral and intravenous medication. However, several challenges still exist in administration. Judith A. Paice, PhD, RN, FAAN, a research professor in medicine-hematology/oncology at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago, Illinois, discussed the management of cancer pain at the 2012 NCCN Annual Meeting.

	According to NCCN guidelines, pain should be assessed for location, duration, intensity, quality (nociceptive, neuropathic, or visceral), timing, and aggravating or alleviating factors. Cancer patients with pain should also be assessed for other symptoms, current therapies, prior treatment response, function changes, family history of substance abuse, and risk factors for aberrant use or diversion.

	“The goals of treatment include prevention, relief of pain, improved function, [and] safety,” Paice said.

	Specifically, she said analgesia versus safety is a major challenge with pain management. For example, while acetaminophen is commonly used for cancer pain, many patients are unaware of how many treatments they are taking that include the drug, increasing their risk of an overdose.

	Currently available treatment options for pain management include non-opioids (acetaminophen or NSAIDs), opioids, adjuvants, and anticancer therapies.

	Opioids are fundamental to good cancer pain management and are available in several forms, including tablets, sublingual tablets, buccal soluable film, and nasal spray. Typically, these agents require prior authorization or partial fills and are associated with a variety of side effects ranging from respiratory depression and sedation to nausea and vomiting.

	Adjuvant options include corticosteroids, antiepilepsy drugs, antidepressants, local anesthetics, NMDA receptor antagonists, and cannabinoids. Corticosteroids can be administered orally, intravenously, or epidurally, and have been shown to be effective in reducing pain. However, corticosteroids may produce psychosis and longterm use may lead to proximal muscle wasting.

	Of the anti-epilepsy drugs, gabapentin is generally the most well-tolerated and is often used for breakthrough pain or neuropathic pain. However, the drug is administered three times per day and may be associated with dizziness and sedation. Pregabalin is another anti-epilepsy drug that has been associated with improved bioavailablity at high doses.

	Antidepressants, including tricyclics (nortriptyline and desipramine) and serotonin—norepinephrine reuptake inhibitors (venlafaxine and duloxetine), have been effective in providing good pain control with limited adverse events. Local anesthetics, such as lidocaine patches or creams, have been effective in treating localized pain.

	Due to the challenges associated with medical marijuana, manufacturers are testing synthetic compounds that target CB1 and CB2 receptors, as these agents provide pain control without the euphoric feeling associated with medical marijuana.

	Overall, Paice said that there are several effective agents available for cancer pain, but practitioners need to be aware of the risk of adverse events and drug-drug interactions associated with these treatments.

Cancer pain management has greatly improved with advances in oral and intravenous medication. However, several challenges still exist in administration.

Challenges and Breakthroughs in Cancer Pain Management

Many targeted therapies are associated with dermatologic side effects, according to Peg Esper, MSN, RN, AOCN®, ANP-BC, an adjunct clinical instructor at the University of Michigan Comprehensive Cancer Center in Ann Arbor. Esper discussed these adverse events at the 2012 NCCN Annual Meeting.

	The most common dermatologic side effects associated with EGFR inhibitors, such as cetuximab (Erbitux) and erlotinib (Tarceva), include papulopustular, xerosis, hypertrichosis, and trichomegaly. Papulopustular most frequently occurs on the face and chest. While the development of rash appears to be correlated with the effectiveness of EGFR inhibitors, the absence of rash does not indicate poor treatment response.

	Prophylactic treatment of EGFR-associated rash involves the use of skin moisturizer creams and ointments, avoidance of excessive sun exposure, avoidance of hot showers or hot water on hands, and avoidance of any alcohol-based products. If a grade 3 rash develops with an EGFR inhibitor, the dose of the agent should be modified and/or an oral steroid added to treatment. However, if a grade 4 rash develops, treatment should be discontinued.

	The dermatologic toxicities most frequently associated with VEGF inhibitors, such as bevacizumab (Avastin) and axitinib (Inlyta), include hand-foot skin reaction, rash or desquamation, hair depigmentation, trichomegaly, paronychia or subungual hemorrhages, xerosis, mucositis, pruritis, bullae, yellowing of the skin and impaired wound healing.

	mTOR inhibitors including temsirolimus (Torisel) and everolimus (Afinitor) are commonly associated with rash. Grade 4 rashes are not common, but if they do occur, treatment should be stopped immediately. Other common symptoms associated with mTOR inhibitors include mucositis and stomatitis.

	BRAF inibitors are associated with rash, photosensitivity, fatigue, pruritus, palmar-plantar dysesthesia, squamous cell carcinomas, and keratoacanthomas. According to Esper, when BRAF inhibitors are used to treat melanoma, it is difficult to tell patients that their treatment is associated with another type of skin cancer.

	Immunotherapy with interleukin-2 may be associated with rash, xerosis, desquamation, pruritis, vitiligo, facial flushing, and stomatitis, while immunotherapy with ipilimumab (Yervoy) may be associated with rash, vitiligo, pruritis, xerosis, and stomatitis.

	Treatment of rash associated with VEGF inhibitors, mTOR inhibitors, BRAF inhibitors, and/or immunotherapies is very similar to that of EGFR inhibitors utilizing creams and ointments and avoidance measures. However, rashes associated with VEGF inhibitors are typically not as severe as with EGFR inhibitors and do not commonly require steroid use.

	Treatment challenges with dermatologic toxicities include patients forgetting details surrounding the start of rash, individual responses to interventions varying greatly, slow improvement with medical treatment, minimal data in the literature for topical applications, late presentation for medical attention leading to complications, and patients avoiding reporting symptoms, Esper said. Overall, monitoring and treating these side effects should be done on an individual patient basis, she added.

Many targeted therapies are associated with dermatologic side effects; the monitoring and treating of these side effects should be done on an individual patient basis.

Managing Dermatologic Toxicities Associated With Targeted Therapies

	With the advent of more targeted approaches to cancer treatment, understanding the genetic basis of breast and ovarian cancers is essential to providing patients with effective preventive and/or management strategies that can improve outcomes. Heather Hampel, MS, CGC, a professor and certified genetic counselor at The Ohio State University Comprehensive Cancer Center in Columbus, discussed the genetic basis for breast and ovarian cancer at the NCCN annual meeting.

	The causes of hereditary susceptibility to gynecologic cancers include hereditary breast-ovarian cancer syndrome, Lynch syndrome (endometrial and ovarian cancer), Cowden syndrome (endometrial and breast cancer), and Li-Fraumeni syndrome (breast cancer).

	Approximately 5% of breast cancers are hereditary and 15% to 20% occur in family clusters, while 10% to 15% of ovarian cancers are hereditary. Heredity breast or ovarian cancer tends to occur at an earlier age and involves multiple generations with cancer or clustering of certain cancers, while sporadic cancer is likely to occur at a later age and occurs as a single or unilateral tumor and is associated with limited family history of cancer.

 account for the vast majority of hereditary breast-ovarian cancer syndrome. 

 mutations increase the risk of primary breast cancer, second primary breast cancer, ovarian cancer, and prostate cancer in men. 

 mutations also increase the risk of breast and ovarian cancer in women, and increase the risk of male breast cancer, as well. In addition, 

 mutations may be associated with an elevated risk of prostate, laryngeal, and pancreatic cancers. Triple-negative breast cancers are more likely due to

 mutations and women aged <60 years with triple-negative breast cancer should be tested, regardless of family history.

-positive cancers are not well understood, individuals of Ashkenazi Jewish descent are ten times more likely to have these mutations than the general public. One in 40 Ashkenazi Jews, both male and female, carries a 

 mutation, while one in 400 carries the mutation in non-Jewish populations.

	The cost of genetic testing for breast and ovarian cancer risk depends on the extensiveness of testing. For comprehensive testing involving both 

 analysis, the cost is approximately $3340; however, most insurance companies will provide coverage if the patient’s need for testing is demonstrated. Follow-up large rearrangement testing is approximately $700 and is not always covered by insurance because the risk of a major rearrangement is rare. Other types of genetic testing include singlesite analysis that costs approximately $475 and evaluates a specific gene that may be found within a family, and Multisite 3 that costs about $575 and looks at three specific mutations commonly found in Ashkenazi Jews.

	According to Hampel, the clinical management of BRCA-positive cancer patients includes increased surveillance, lifestyle changes, chemoprevention, and prophylactic surgery. Surveillance for 

 mutation carriers includes monthly breast self-exams starting at age 18, clinical breast examinations every 6 months starting at age 25, and annual mammography and breast magnetic resonance imaging starting at age 25. Surveillance will also involve ultrasound with color Doppler imaging every 6 to 12 months, starting at 30 to 35 years of age.

	In some BRCA-positive patients, especially in patients with 

 mutations, chemoprevention with tamoxifen may be prescribed. Oral contraceptives may also be used to prevent the risk of ovarian cancer. In the general population, oral contraceptives reduced the risk of ovarian cancer by 40% to 50% after 3 years of cumulative use. However, the benefits and risks of oral contraceptives for chemoprevention and contraception need to be weighed.

	One popular option for the prevention of breast cancer is prophylactic mastectomy, which removes most, but not all, breast tissue. The approach has been shown to reduce the risk of breast cancer by 90% to 95%. Another approach is prophylactic oophorectomy, which decreases the risk of ovarian cancer by 85% to 90%. It is crucial that patients are fully informed of the latest clinical information before selecting either of these options.

 testing might also help guide treatment. Currently, Poly-ADP ribose polymerase (PARP) inhibitors are being studied for the treatment of BRCA-positive breast and ovarian cancers. “PARP inhibitors have the potential to enhance cytotoxicity of cancer treatment and reverse tumor cell resistance,” Hampel said.

Understanding the genetic basis of breast and ovarian cancers is essential to providing patients with effective preventive and/or management strategies that can improve outcomes.

Genetic Assessment of Breast and Ovarian Cancer Risk

		Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

 Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

		Louisiana State Health Sciences Center in New Orleans, Louisiana

	Each year at its annual meeting, the National Comprehensive Cancer Network (NCCN) presents updates to its Clinical Practice Guidelines in Oncology. The NCCN also conducts an oncology nursing educational program at the yearly gathering. This month’s issue of 

, which was held on March 14 at the NCCN’s 17th Annual Meeting in Hollywood, Florida.

	The full-day oncology nurse program was accredited for 6.85 continuing nursing education hours. Sessions were conducted by oncology nurse experts and certified genetic counselors from around the country. Our coverage spotlights key areas covered in the program, including genetic assessment of cancer risk, challenges with managing oral cancer treatments, management of dermatologic toxicities associated with targeted therapies, challenges and breakthroughs in cancer pain management, and essential components of survivorship care.

’s coverage of the NCCN’s annual meeting will continue in our May issue with a complete breakdown of the latest guideline updates. Guidelines covered will include colorectal cancer, Hodgkin lymphoma, non-Hodgkin lymphoma, advanced renal cell carcinoma, multiple myeloma, melanoma, lung cancer screening, non—small cell lung cancer, breast cancer, prostate cancer, ovarian cancer, acute lymphoblastic leukemia, and central nervous system metastases.

	As a primer to our NCCN coverage, I wanted provide you with some background information on the NCCN itself. When I visited the NCCN’s website to conduct research, I realized that its operations were much more extensive than I had previously thought.

	The NCCN is a nonprofit alliance of 21 leading cancer centers. As you are aware, it is best known for its oncology practice guidelines, recognized by many as the most frequently updated clinical guidelines available in any area of practice. The NCCN Guidelines are developed through an evidence-driven process with explicit review of clinical trial data by multidisciplinary panels of expert physicians from NCCN Member Institutions. Treatment recommendations are specific and can be easily implemented in any type of practice (eg, community oncology).

	In addition to developing cancer treatment guidelines, the NCCN has developed guidelines for supportive care of patients experiencing fatigue, distress, and nausea and vomiting. There are also guidelines available on palliative care and use of myeloid growth factors. Some of these guidelines (eg, antiemesis and cancer-related infection) are available in pocket-size for easy access and reference.

	The NCCN has also developed guidelines for cancer detection, prevention, and risk reduction. These include guidelines on screening for breast, colon, and lung cancer, as well as genetic/familial high-risk assessment of individuals at risk for breast and ovarian cancer. Age-related guidelines have been developed for adolescent and young adult oncology practice and senior adult oncology care.

	To keep abreast of NCCN developments, oncology professionals can subscribe to NCCN Flash Updates, a service from the NCCN that provides timely access to updated and new information appearing in the NCCN Guidelines, the NCCN Drugs & Biologics Compendium, and other NCCN content. Additionally, archived and live webcasts (some with continuing education credit for nurses and physicians) are available on the NCCN website.

	Print and electronic patient information on breast, colon, prostate, myeloma, and other cancer types is also available through the NCCN’s website. The purpose of the patient-directed materials is to provide patients with information that will help enable them to make informed decisions about their care. As noted in the patient guidelines, patients in smaller communities without access to a medical library or research center can learn about the latest clinical trial data.

	When I visited the NCCN’s website to conduct research, I realized that its operations were much more extensive than I had previously thought. ”

	One of the newest areas in NCCN development is creation of order set templates for chemotherapy, immunotherapy, and supportive care agents. The NCCN hopes that utilization of these treatment templates will help standardize cancer treatment, ensure that up-to-date treatment is provided, and reduce medication errors.

	Another interesting area covered on the NCCN’s website is the section on global implementation of NCCN Guidelines. Many NCCN guidelines and resources are available in languages such as Spanish, Chinese, Japanese, and Korean. There is a great potential to implement the NCCN Guidelines worldwide.

	If you equate the NCCN with treatment guidelines and not much more, as I initially did, take a look at its website. You, too, will be surprised at the diverse and clinically applicable resources available from the NCCN.

Nurse's Notes

Each year at its annual meeting, the National Comprehensive Cancer Network presents updates to its Clinical Practice Guidelines in Oncology.

April 2012