Individuals who have cancer want to be seen for who they are, not for the disease they have, which becomes difficult when it presents itself, literally, on the face they show to the world.

One of the most difficult aspects of head and neck cancer is its public nature. Evidence of many other cancers is not always visible, but when treatment results in disfigurement of the head and neck, survivors must learn to cope with those effects. Nurses need to be prepared for the social and emotional toll the disease may take on these patients, as well as the complex comorbidities that often accompany it. This is where nurse educators like Colleen O’Leary, MSN, RN, AOCNS, highlighted in the cover story of the 

, come in. O’Leary trains others on how to support head and neck cancer survivors. She teaches and practices evidence-based care, emphasizing the need for sympathy and understanding for what can be a difficult patient population with complex comorbidities.

Also in this issue: How should nurses address the trend of patients fasting during cancer treatment? Some patients say fasting offers some benefit, and animal studies have demonstrated that it reduced toxicity and increased efficacy of chemotherapy, but there is not yet enough research to say for certain. Because the jury is still out, Editor-in-Chief Lisa Schulmeister, MN, RN, FAAN, urges nurses to be aware of this trend and be able to discuss it with patients, especially those who should not be fasting.

This month’s feature story focuses on an oncology nurse who is also a fitness trainer and educator. Alene Nitzky, PhD, RN, OCN, synthesized her skills and education into a consulting business that caters to cancer survivors looking for extra support outside the hospital setting. She incorporates creativity, authenticity, resourcefulness, and empathy in wellness consulting. Her book Navigating the C discusses the different stakeholders in cancer care and how all can do a better job of supporting people going through the cancer experience.

 also features a nurse navigator’s first-person experience supporting patients with cancer who were displaced by hurricanes, as well as a column on the ethics of doing favors for patients. It also highlights a study in which acupuncture reduced joint pain for patients who were treated with aromatase inhibitors.

In addition, Angela Treanor, RN, BA, explains how nurses who participate in fund-raisers do more than just raise money—they share their belief in hope for the future of oncology. Lastly, this issue’s clinical insights offer background on the US Preventive Services Task Force’s (USPSTF’s) recommendation against ovarian cancer screening in average- and low-risk women; how older patients with colorectal cancer are more likely to develop cardiovascular disease; the significance of geography, race, and genetics in endometrial cancer; and exercise’s effects on the recovery of arm mobility in women who have had lymph node dissection. We hope you find 

 informative—and, as always, thank you for reading.

Articles

From the Chairman

This letter from the Chairman and CEO of Oncology Nursing News® gives an overview of the contents of the April 2018 print issue of the magazine. 

Combining Relationship-Based Care With Evidence-Based Practice Can Improve Your Nursing Game

 Alene Nitzky, PhD, RN, OCN, helps survivors on the road to wellness using a unique blend of complementary skills. As an oncology nurse who is also an exercise trainer certified by the American College of Sports Medicine and the American Cancer Society, Nitzky draws on her varied training to address the often complex survivorship needs of people who have completed cancer treatments but feel they need further support to reach a new normal.

Nitzky started out as a health educator, became a personal trainer, and in her 40s, returned to school to become a nurse. While working as an oncology nurse in a hospital infusion clinic, Nitzky listened to her patients talk about the issues they faced and sensed that they felt adrift once their treatments ended.

She started attending community support groups to get a feel for patients’ concerns once they finished their medical treatments. Over and over, she heard how people thought that after treatments were over, they would be back to normal. But aftereffects and consequences of treatment can be long-lasting, and some will never go away. Recovery can be a complicated and sometimes slow process, and survivors often flounder, dealing with physical and emotional issues they didn’t expect to have as a part of their postcancer life.

“People get through treatment and don’t have an idea of how they’re going to feel,” Nitzky says. “They don’t have an idea of what’s realistic for themselves.”

As she listened to her patients and the support group attendees, she realized that she could help fill that posttreatment need for support. “I realized I would be able to work with survivors, because I have a background in recreation, health, exercise, and oncology,” she says. “I could put all this together. It makes sense. Everything in my life has pointed to this.’ ”

Cancer Harbors is Nitzky’s 6-month skill-building program for selfcare. Through the program, she coaches survivors to be advocates for their own health, helps clients understand what to ask providers, and encourages them to gain the confidence to ask those questions.

Survivors expand their resource base for recovery from treatment, learn about a variety of community resources for self-care, and find out what helpful products and services are available. Nitzky also helps survivors set goals, define their values, and understand what is most important to them.

Nitzky also runs a free support group for survivors called FIERCE: Functional & Fit, Independent, Energized, Restored, Confident & Empowered at the Raintree Athletic Club in Fort Collins, Colorado.

The gym’s location appeals to FIERCE participant Jean Lehmann, who would rather not spend time in a medical setting now that she has completed treatment. She also appreciates being among survivors who do not dwell on their illness but, instead, understand her issues.

“We don’t really talk about having cancer,” Lehmann says. “I want to be Jean first. But I’m with people who—if something comes up&mdash;they all get it. Because they’ve been there.”

Over the past 3 years, the FIERCE program has evolved beyond stretches and exercises to include an array of fitness techniques. Nitzky brings in speakers to introduce survivors to tai chi, biofeedback, qigong, Pilates, and yoga—each practice offering a different approach to physical recovery from the effects of cancer or its treatment&mdash;as well as a nutritionist to discuss diet.

“People might benefit from talk support groups for a little while, but they need to move on, have some normalcy in their lives, and expand their horizons,” Nitzky says. “Our group also helps with the cognitive aspects [of recovery]. Survivors might have brain fog, feel anxious, or feel like they’re not thinking clearly. Interaction, exercise, and learning new things is so good for them.”

Nitzky takes a holistic perspective, incorporating relaxation techniques and advice on dealing with aftereffects and anxiety. She tries to personalize topics and exercises to the participants, based on their requests and conditions.

As a certified cancer exercise trainer, Nitzky understands patients’ specific needs. “For example, if a person has low platelets, you don’t want them to do any impact activities,” she says. “If their immune system is weak, you don’t want them around a lot of other people. If they have lymphedema or they’re at risk for lymphedema, you have to be careful about the kinds of exercises you do, so you don’t trigger that.”

Cancer treatment affects survivors’ abilities, so she considers whether a participant has recently finished radiation or had surgery, for example. She realizes that they may have lost muscle mass or developed anemia after chemotherapy, and their bone marrow may not have recovered. “You have to be careful about how hard people push themselves, because you don’t want to deplete their muscles and their heart of oxygen. You want to make sure they ease into it,” Nitzky says.

Jane Kinney, who is 5 years past her surgery for stage IV thyroid cancer, attended the FIERCE support group and found the expertise valuable. Nitzky identified medical issues that arose after Kinney’s surgery, during which 59 lymph nodes were removed. “One of my cheeks would swell way up. The surgeon basically just dismissed it,” Kinney says. “I didn’t know, but it was just lymphedema. Alene was the one who identified it. She knew what it was right away.

“I also would sometimes have pain all over my body,” Kinney says. “I thought, ‘That’s just the way it is.’ But when I mentioned it to Alene, (she) suggested that I might need more vitamin D. She told me to talk to my doctors, and I did, and they gave me a pretty high dose of vitamin D. Alene made my quality of life so much better.”

Drawing on her broad experience with survivorship care, Alene Nitzky, PhD, RN, OCN, wrote Navigating the C: A Nurse Charts the Course for Cancer Survivorship Care, a book that discusses the different stakeholders in cancer care and how they can all do a better job of supporting people going through the cancer experience. To improve survivors’ health, quality of life, and outcomes, as well as reduce healthcare costs, she recommends an approach that incorporates creativity, authenticity, resourcefulness, and empathy—or CARE&mdash;at all levels of the healthcare system. The book contains samples of materials used in the Cancer Harbors and FIERCE programs, and in an appendix, Nitzky proposes a cancer literacy program to help reduce the general public’s fear, trauma, and misinformation around cancer. For more information, visit cancerharbors.com/navigating-the-c.

Feature Story

Alene Nitzky PhD, RN, OCN, incorporates creativity, authenticity, resourcefulness, and empathy into her career as a wellness consultant to survivors.

After Cancer Treatment Ends, This Nurse's Work Begins

Oncology nurses should aspire to give care that goes above and beyond what is necessary to assure the safety and wellbeing of their patients. They are charged with reducing the suffering of patients with cancer but also should do what they can to ensure a positive patient experience. Today’s healthcare environment is competitive, and, practically speaking, care is partially judged by patient satisfaction.

There is, however, a gray area between what qualifies as excellent professional care and what crosses the line into inappropriate behavior. Is doing a favor for a patient simply providing excellent care? What determines if a favor is reasonable? Ask these 3 bottom-line questions. Is the behavior:

The first 2 questions may be easier to answer, but the last can be tougher. It might help to consider if the action could be done for any patient. The real-world scenarios below might also help guide you.

Martin is on the inpatient oncology unit on bed rest, with only bathroom privileges. He asks if anyone going downstairs would be willing to buy him a couple of magazines using his money. As his nurse, you agree to do so.

The exchange of money between a patient and healthcare professional can be tricky and could become a he said/she said situation. Having someone witness when the patient gives money to the nurse and providing the patient with the receipt helps protect staff. Consider contacting volunteer services, which may offer reading materials, lending libraries, or humor and art carts.

The next day, Sarah, another patient on the same unit, learns that Martin had staff get him some magazines. She asks if someone could pick her up some chips. Your colleague who is caring for her states, “Sorry, I can’t do personal favors for patients.” Now Sarah thinks that Martin got special treatment.

It is not that one nurse was right and the other wrong—different nurses have different boundaries regarding personal versus professional behavior. In this situation, the action was not illegal or unsafe but might be considered outside the scope of professional care.

John finishes a treatment in the outpatient infusion area and learns that his ride can’t pick him up after all. He asks his nurse if the cancer center volunteer could give him a lift just this once. She lives about 10 minutes from his house, and they have formed a special relationship.

Hallie comes alone to the same cancer center because her family members are day laborers—if they  do not work, they do not get paid. This rural area has no mass transit, ride-share, or taxi service. The nurse navigator usually offers her a ride home because Hallie lives along her commute.

John asks a favor of a volunteer (just this once); Hallie's nurse navigator offers (frequently) to give her a ride home. Is there a difference in policy or guidelines for a volunteer versus an employee? Is the situation different if the patient asks for a favor versus a nurse offers it? Does it matter if a favor occurs once versus all the time?

Although these situations differ slightly, the main concern is the same—safety. Suppose there was a car  accident or the patient fell while walking from the car. Who would be liable? This behavior most likely violates the employer policy for both the employee and the volunteer. Employee guidelines usually apply to volunteers, who are considered an extension of hospital staff and follow the same privacy and safety rules.

If a ride is given 1 time, the patient (and probably coworkers) might expect it again. When other patients hear about it, the situation may escalate to where many patients assume that staff can provide  transportation services. Bring the matter to management’s attention so that a proactive plan can be put in place for these situations.

Mariana’s fluorouracil pump is due to be disconnected Thursday afternoon. Her daughter, who usually drives her, unexpectedly had a work situation she could not get out of come up, and Mariana has no way to get to the office. If her pump is not disconnected, the alarm will go off and might upset her. One of the infusion nurses realizes that Mariana lives in an area that’s on her commute, so she stops at Mariana’s home, disconnects the pump, flushes the line, and brings the pump back to the office.

This action is likely unsafe and possibly illegal. Providing home care is likely outside the scope of practice of an outpatient infusion nurse. If something were to happen, the nurse—and potentially her employer&mdash;could be held liable, since this is a patient under their care. Alternative solutions include coaching Mariana over the phone about how to turn off the pump or seeing if a home care nurse could help.

Rajesh is a patient with end-stage disease and not yet on hospice. He has run out of his narcotic analgesic. He lives alone and is unable to come to the office, but if his meds are not refilled, he will  begin to have a great deal of pain. His office nurse asks his physician to write a script, which she delivers to Rajesh on her way home from work. His sister will be able to take it to the pharmacy the next day.

Although this may not be illegal, unsafe, or unprofessional, the issue is that it cannot be done for everyone. What if another patient learns that a prescription was delivered? Could delivery become an expectation or seem like favoritism? Alternative solutions include calling in the prescription to a pharmacy that delivers or connecting with a volunteer organization that serves Rajesh’s community.

Helping in a personal relationship is very different from in a therapeutic, professional relationship. Knowing the differences can promote early recognition of a potential boundary crossing and prevent workplace conflicts.

Before doing a favor, quickly reflect on its consequences and impact. Think through potential perceptions from all sides—patients, colleagues, managers, employer. Consult with trusted colleagues. Consider contacting a manager to make sure actions align with employer guidelines. Favors may be done with good intentions but backfire if the behavior is illegal, unsafe, or unprofessional.

Sometimes oncology nurses get into sticky situations with favors because they try to do everything themselves, but that can cause the nurse to have feelings of inadequacy that can lead to moral distress, compassion fatigue, and burnout. Reach out to social work, volunteer services, management, or other team members to explore potential resources or help brainstorm possible solutions.

Professionally Speaking

Navigating the gray area between excellent professional care and inappropriate behavior can be difficult.

Doing Favors for Patients

Mother Nature is wreaking havoc on our world. In the past year, we have experienced massive snowstorms, mudslides, hurricanes, and floods. Dealing with weather emergencies is difficult even in normal circumstances. When a person has cancer, the difficulties are multiplied.

I am an oncology nurse navigator in Philadelphia, Pennsylvania. Last year I was faced with the challenge of trying to navigate oncology patients from the southern United States whose lives were disrupted by the 2 hurricanes that devastated both Florida and Texas. Harvey and Maria are names I will never forget.

One memorable case involved a woman I will call BB. She was 66 years old. She lived in southern Florida and had multiple myeloma. BB was in the middle of treatment with cyclophosphamide (Cytoxan), bortezomib (Velcade), and prednisone. She called to ask what I could do to help her get treatment, because she was being evacuated and coming north to stay with friends. She was driving up alone. She had no family, and her usual support system, her network of friends in Florida, would also be evacuating.

I did an assessment over the phone and tried to get as much information as possible. Her doctor had given her copies of her records to take wherever she went, because he did not know whether her hospital or cancer center would still be standing after the storm went through. He wished her good luck and said he hoped he would see her again. BB told me how scared she was. She would be in the Philadelphia area by the time of her next treatment, which was a week away.

I registered her in our system and vetted her insurance. I asked where she would be staying, as we have a large network of satellite facilities that I could use if needed. I wanted to make this transition as smooth as possible. We agreed to talk again the next day.

“I am in your hands,” she told me. “I trust you to help me get through this.”

I felt a deep burden of responsibility to help BB overcome her challenges and access her treatment. My next step was to reach out to local providers. This was another hurdle, as we did not have records at the time and were basing her appointment on my assessment. My idea was to have her seen in one of the satellite facilities nearby so she would not have to drive in to the city. This would be best for her, especially if she needed to be here long term for continued treatments.

After a lot of juggling, I was able to get an appointment with one of our medical oncologists, as well as an infusion chair for treatment so she could stay on track. I spoke with BB daily to keep her updated on her new plan of care and made sure to keep her provider in the loop in case there were any glitches in her travels north.

BB arrived safely, tired but relieved to have that part of her journey over. She stayed in our area for several treatments, and then went back to Florida when it was safe for her to return. BB was one of the lucky ones whose home survived with minimal damage. Many of her friends were not as lucky. BB was most appreciative of having a navigator to guide her and told me she would have been lost without my help. She keeps in touch with me and is doing well and happy to be home.

I got several other calls from oncology patients in the South who needed help in trying to continue care. It was devastating for them to have to face the fact that their lives might never be the same, and home and comfort as they knew it might no longer exist. While working to accommodate these patients, I wore many hats—that of nurse, counselor, educator, and travel agent, to name a few. I followed the same game plan for each call and was able to successfully get everyone in who needed treatment. All my patients were able to be scheduled, and it felt good to know I could help them during that difficult time.

Being a nurse navigator is challenging, and no 2 days are ever the same. We constantly use our critical thinking skills and think outside the box to help our patients through the disease trajectory, no matter when or where it happens. They face challenges each and every day while battling their cancer.

Meeting these incredible people through this journey showed me how strong they are. They are survivors and fighters and prove that where there is a will, there is a way.

PRO TIPS FOR PREPARING TO HELP DISASTER VICTIMS

If you are expecting patients relocating temporarily due to weather disasters, here’s how you can prepare to help them continue care without disruption:

Do an assessment before they arrive to try to get as much information as possible in advance

Register the prospective patient and vet insurance

Be mindful of logistics; if they arrive without their own transportation, try to schedule treatment close to their temporary residence

Peg Rummell is an oncology nurse navigator at the Abramson Cancer Center, Penn Medicine, in Philadelphia, Pennsylvania.

Nurse Navigators

One versatile nurse used creative ways to ensure that displaced patients received their treatments on time.

A Navigator Helps Patients Weather the Storms

The call bell light in room 12-204 was the first to go off at the crack of dawn, breaking the serene silence of the floor. “I need to shower so I can see the race!” the patient exclaimed.

She carefully selected her robe and stood eagerly in her doorway, announcing to every passerby that she was ready. Bundled in multiple scratchy hospital blankets to ward off the morning chill, she and other staff members made their way outdoors. They joined a throng of other patients with cancer, as well as survivors.

The early riser’s nurse, Mario Lupone, had told her the night before that he was riding 62.5 miles across the Connecticut terrain to honor her fight with cancer. She was not going to miss wishing him luck.

“Seeing her outside with all the other patients makes you feel great about being an oncology nurse and why we do what we do,” Lupone said. As a charge nurse known for his bright cheer and corny jokes, he has raised over $15,000 as a Closer to Free Ride participant.

The Closer to Free Ride is an annual Connecticut cycling event—100% of the funds raised go toward patient care at Smilow Cancer Hospital and research at the Yale Cancer Center. These funds play an important role in multiple facets of cancer care, such as providing genetic counseling to high risk patients, providing resources toward melanoma research, expanding the availability of clinical trials, and funding survivorship clinics. Riders raise a minimum of $500 by soliciting donations.

In September 2017, hundreds of riders of various cycling levels launched from the Yale Bowl and  pedaled through the winding New Haven streets. Some bikes sported ultralightweight carbon fiber frames with vibration-canceling composite technology, while others flaunted aerodynamic handlebar tassels and trundles, along with helmeted children. When they approached the hospital on Park Street, the undulating wave of blue and white riders slowed for the “Smilow salute.” Riders disembarked to hug and shake hands with cancer patients cheering in front of the hospital. Bright yellow bands on jerseys signified cancer survivors. Other participants included family members riding in memory of loved ones, as well as oncology nurses who care and support patients with cancer in every stage of their battle.

One nurse, Maureen Raucci, was captain of Team Live Positive, which has raised over $843,000 for cancer research since 2010. In 2017 alone, the team raised an incredible $192,603.

As a nurse manager on a medical oncology unit of Smilow Cancer Hospital, Raucci witnesses not only the battles fought by many patients but also the positive light that the patients exude—and the source of the team’s name. When she first heard about the Closer to Free Ride in 2010, Raucci knew that she had to start a team. “I knew all the positivity and healing that would come from the ride, and I knew that I had to be a part of that here,” she said.

In its inaugural year, Team Live Positive consisted of 12 friends riding in honor of 2 friends battling melanoma and leiomyosarcoma. In 2017, Team Live Positive comprised 122 riders, assisted by many more volunteers. Raucci kept members engaged all year through Facebook posts and e-mails featuring a Survivor or Patient of the Week.

The reaction from patients who see their nurses alongside them in the Closer to Free Ride is incredibly affirming, Raucci says: “They feel wholeheartedly and holistically supported by their team, both in the hospital and outside of the hospital.”

Raising over $843,000 over 7 years has actually been easy for the team, according to Raucci. “For us as nurses, if we just share our story, people are willing to give,” she said. “Every dollar counts. Our team motto is ‘Each mile we ride, every dollar we raise, brings us 1 step closer to free.’”

Brianna Lutz, another member of Team Live Positive, believes that participating is therapeutic for the providers who work in this emotionally demanding field. “Often, in inpatient oncology, it’s easy to get lost in the sad stories and feel like the negativity is overpowering,” says Lutz. “Fund-raising efforts are an important reminder that there is hope, and there is a lot of research on the horizon to look forward to.”

At the end of the day, the wheels stopped turning and the kickstands scraped down into the ground. Dust and grime from hundreds of miles coated the bikes, and riders compared blisters and complained about sore butts. The sweat-soaked jerseys stayed on as long as the smiles brightened tired faces. Riders, their bikes attached to racks or haphazardly jammed into SUVs, drove back home. While some Closer to Free Ride participants were avid cyclists who would continue to pump away on slick roads or off-beaten paths in the days ahead, others would store their bikes for the fall.

For patients with cancer, the journey does not end. Each mile covered in their fight against cancer is a victory. Oncology nurses are there at every bend and hill. The nurses on Team Live Positive go above and beyond their call of duty, pedaling for a cause that is close to their hearts, so that every oncology patient can be closer to cancer-free.

Angela Treanor, RN, BA, is an oncology nurse at Smilow Cancer Hospital at Yale New Haven in Connecticut. She is pursuing her MSN at Yale University.

Partner Perspectives

Oncology Nurses in Fund-Raising

How is your appetite?” you ask. Your patient receiving chemotherapy responds, “I’m fasting.”

Now what? Are you prepared to engage in a discussion about fasting during cancer treatment? Probably not.

How many patients fast is unknown; however, posts on online blogs and cancer support group websites indicate growing interest in fasting—and suggest that patients are not necessarily informing their healthcare providers that they are fasting during treatment. Patients who disclosed the practice found their oncologists to be dismissive, opposed to fasting, and uninformed.

Fasting is gaining popularity as a way to improve health, lose weight, and even reverse type 2 diabetes. There are different types, including water fasting (drinking only water and water-based beverages, such as tea and coffee with nothing added), dry fasting (abstaining from all food and liquid), and restrictive fasting (limiting certain foods). The duration can be continuous for a defined period (usually 24 hours but could be up to several days), intermittent, with food eaten at prescribed times during a 24-hour period, or whole-day fasting for 1 or 2 days each week.

Why the emerging interest in fasting? In findings from several animal studies, fasting appeared to both reduce toxicity and increase efficacy of chemotherapy. It also may increase the efficacy of targeted kinase inhibitors (TKIs), although its effect on TKI-related adverse effects is still being studied. The key to the protective factor observed in fasting mice may be a genetic signaling pathway called PKA/EGR1. It appears that when normal cells are deprived of nutrients, they are protected from chemotherapy while dividing cancer cells expend energy while “starving” and are then more susceptible to “attack” by chemotherapy. Also, fasting reduces protein kinase A (PKA) activation and increases AMP-activated protein kinase (AMPK) activity. These signal transduction changes and cause the activation of the early growth response protein 1 (EGR1).

Although animal trials are promising, can the results be translated to patients? In a case report of 10 patients being treated for a variety of cancers, those who fasted (water only or with vitamins) for a total of 48 to 140 hours prior to and/or 5 to 56 hours following chemotherapy reported greater tolerance to treatment and less fatigue, weakness, and gastrointestinal symptoms compared with previous nonfasting treatments. Fasting also did not appear to prevent chemotherapy-induced tumor shrinkage or affect tumor markers. Minor complaints during fasting included dizziness, hunger, and headaches at a level that did not interfere with daily activities; weight loss was rapidly recovered.

In a 2016 study, 20 patients receiving platinum-based regimens fasted for up to 72 hours (48 hours prechemotherapy and 24 hours postchemotherapy infusion). They were instructed to consume no calories, and to drink water and noncaloric beverages; if symptoms related to fasting occurred (eg, feeling faint or weak), they could consume a small amount of juice or food (<200 kcal in a 24-hour period). There were no grade 3 toxicities attributed to fasting, and laboratory studies revealed no evidence of malnutrition. The researchers cautioned that the safety of fasting prior to chemotherapy can be extrapolated to just a selected population of patients because they excluded those with more than 10% recent weight loss, body mass index of less than 20.5, or diabetes mellitus.

Randomized trials are needed to conclusively determine the impact of fasting on cancer treatment efficacy and adverse effects. Researchers at Mayo Clinic are enrolling patients in a clinical trial to assess the safety and feasibility of short term fasting prior to chemotherapy administration.3 They also are evaluating the effect of fasting on weight changes, determining the longest feasible fasting period prior to chemotherapy, and investigating changes in plasma glucose, insulin, insulin-like growth factor 1 (IGF-1), and IGF-1binding proteins. The trial is expected to conclude in August 2018.

Animal data and clinical findings from 2 small studies suggest that fasting during cancer treatment is not harmful and may be beneficial. Since it is easy to do—and within a person’s control&mdash;it’s understandable that patients may want to fast during treatment. But for how long should they fast, and how should fasting be timed in relation to chemotherapy? These are the great unknowns. In the ongoing Mayo Clinic trial, 1 cohort is fasting for 24 hours before day 1 of course 2 of chemotherapy. If the fast is well tolerated, they may escalate fasting by 12 hours for each subsequent course for up to 3 courses in the absence of unacceptable toxicity. A second cohort is following the longest fasting regimen found to be safe and tolerable in cohort I before day 1 of each course of chemotherapy for up to 4 courses in the absence of unacceptable toxicity.

The limited evidence suggesting a beneficial effect of fasting during cancer treatment has spawned unproven claims, such as fasting to treat cancer or prevent recurrence. Claims that fasting for 3 days “renews the entire immune system” also have been made. Unproven products, including liquids and supplements, are being marketed to “ensure” effective fasting during cancer treatment. It is, therefore, imperative that oncology nurses be informed about fasting, maintain a nonjudgmental attitude, and discuss it with their patients. Nurses need to caution patients to not fall prey to unproven claims and products.

Lastly, fasting is not appropriate for all patients receiving cancer treatment. People who have eating disorders, diabetes, or low body mass index (<20.5) or who lost more than 10% of their weight in the preceding year.

Nurses must know how to identify the patients that may benefit and refer them to reputable resources.

Safdie FM, Dorff T, Quinn D, et al. Fasting and cancer treatment in humans: a case series report. 

. 2009;1(12):988-1007. doi: 10.18632/aging.100114.

Dorff TB, Groshen S, Garcia A, et al. Safety and feasibility of fasting in combination with platinum-based chemotherapy. 

. 2016;16:360. doi: 10.1186/s12885-016-2370-6.

Short-Term Fasting Before Chemotherapy in Treating Patients With Cancer.  clinicaltrials.gov/ct2/show/NCT01175837. Updated November 17, 2017. Accessed February 5, 2018.

Nurse's Notes

There is not yet enough research to support a medical stance on fasting during cancer treatment despite growing patient interest in the practice.

Fasting During Cancer Treatment

Head and neck cancer treatments can cause serious damage to an individual’s appearance and self-image. Nurses need to be prepared to provide survivors with both medical and emotional support in dealing with the aftereffects.

According to the American Cancer Society, an estimated 436,060 survivors of head and neck cancer are living today in the United States, and that number is growing.

 Survivors often cannot escape the effects of their disease because of the prominent location of their cancers. Their recovery postsurgery remains very visible to the outside world.

When patients are told that they might lose sight in an eye or lose a section of jaw due to head or neck cancer, multidisciplinary teams play a key role. Compassionate specialists and healthcare providers ready to address questions and needs are crucial to enabling patients to navigate the road ahead. Nurses are vital members of this multidisciplinary care team.

Disfigurement is a significant concern for patients with head and neck cancer, according to Colleen O’Leary, MSN, RN, AOCNS. “Although there are other disfiguring surgeries, such as mastectomy or colostomy, often those can be hidden with prosthesis or clothing,” she says, “but when it’s your face or neck, you can’t hide it.”

Nurses help these survivors learn how to come to terms with their new normal. Through her dual associate director roles at Ohio State University Wexner Medical Center in Columbus, O’Leary educates nurses about incorporating compassion, as well as evidence-based practice, into the work of oncology nursing. She serves as an associate director of nursing education at The Ohio State University Comprehensive Cancer Center Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (The James), and as associate director of Evidence Based Practice (EBP) at the Wexner Medical Center.

Before she became a nurse, O’Leary was a social worker. For 26 years, she incorporated lessons she learned in social work into her oncology nursing practice: How to view and treat the whole person and to try to understand patients’ family, work, and social environments as part of a method of care.

“That ability to talk to patients, to see them for who they are and not their disease, has been invaluable,” O’Leary says.

O’Leary came by some of this understanding the hard way. In and out of hospitals as a child, she viewed nurses as her “second moms.” Through personal experience, she learned what a difference a nurse who develops a relationship with a patient can make. The professional model of relationship-based care is institutionalized at The James, where clinicians integrate care of patients and family, colleagues, self, and community. “I take that vision of nursing at The James and weave it into my daily routine,” O’Leary says.

This model is crucial for both patients and those working in the head and neck cancer specialty. Patients need support for a multitude of issues that surround survivorship.

When explaining to nurses how to support patients with head and neck cancer, O’Leary stresses a key message: “Not judging someone for their lifestyle is critical.”

Most head and neck cancers begin in squamous cells, which line moist surfaces such as those in the mouth, nose, and throat. Tobacco use, heavy alcohol use, and infection with human papillomavirus (HPV) increase the risk of many types of head and neck cancer.

O’Leary has observed that providers may find it difficult to care for these patients because smoking and alcohol and drug abuse often contributed to the growth of their cancers. Addicted patients are hard to treat. “Knowing that something they may have done in their past led to this can be difficult,” she says.

Nurses must retain their objectivity and not play the blame game. “It is important to treat everyone with compassion and respect,” O’Leary says. “Know that this diagnosis has changed them inside and out, and support them through that.”

Patients’ overall coping skills can be an important but often overlooked issue in head and neck cancer treatment. For example, drug abusers may have to detox prior to surgery. “We have had to cancel surgeries because patients could not quit using,” O’Leary says. “We have tried to set up detox programs prior to surgery. Patients who are willing to participate [in these detox programs] have a much better outcome. Also, as younger and more educated patients are on the rise [with HPV-positive head and neck cancer] outcomes are better.”

Head and neck cancer survivors are often not prepared for how they will look immediately after surgery. The changes to their body can be overwhelming, and they may need a lot of support.

They should be able to rely on nurses as a good source of knowledge, so O’Leary provides relevant clinical education to her staff to ensure that survivors are receiving competent care.

“Most often the patient will have chemoradiation after healing from surgery, so [adverse] effects of both need to be assessed and reviewed with each treatment. Mucositis is prevalent 100% of the time in patients with head and neck cancer who are receiving chemo and radiation at the same time. Teaching them what to expect and trying to head off severe pain is imperative,” O’Leary says, adding that nurses and patients need to be aware of other prominent adverse effects (AEs), including nutritional issues related to mucositis, psychosocial issues, and chronic xerostomia.

EVIDENCE-BASED PRACTICE AND PROFESSIONAL DEVELOPMENT

Mucositis is an extremely common AE for survivors of head and neck cancer, and many patients at The James are receiving a new type of treatment for oral lesions based on an EBP project. “We have a nurse-run clinic using low-level laser therapy to treat oral mucositis, and there is evidence that it is useful for prevention, as well,” O’Leary says. “It is helpful in reducing mucosal lesions in size and can reduce the number of times that chemotherapy is held.” Decreasing the number and size of mucosal lesions can also lead to an overall decrease in the rate of infection, because the lesions are less open and active after laser therapy.

“We have gotten to the point where we don’t just do EBP projects—we are using EBP decision making at all levels at The James,” O’Leary says. “All nursing councils have an EBP mentor on them. We base all decisions on evidence when possible.”

Throughout her career, O’Leary has seen many EBP projects lead to huge changes for oncology patients everywhere.

For example, O’Leary was part of the Oncology Nursing Society’s Putting Evidence Into Practice (PEP) project, a group focused on infection prevention and oral mucositis. She helped write oncology recommendations for nurses in a pocket style guide.

One patient in particular helped O’Leary understand that survivorship comes with unique challenges that can affect each patient differently. The night before she was to present at a daylong conference on head and neck cancer, she met a long-term survivor who was also slated to speak, and he described his challenges to her.

“He was a teacher and so he spoke a lot, but now he had long-term xerostomia that required him to always have water with him,” O’Leary recalled. “He had issues with drooling so needed to keep tissues with him, and at times he was difficult to understand. His life had changed significantly, but he was making it work.”

Head and neck cancers are often complex, involving painful AEs and can affect a patient’s life in unexpected ways. Nurses can be most effective in their work by keeping up on the latest developments and listening closely their patients.

In 2016, a head and neck cancer survivorship guideline was released in 

a journal of the American Cancer Society. A collaboration between the CDC, American Cancer Society, and George Washington University Cancer Institute led to the guideline’s development. This resource aims to better educate both patients and providers on long-term goals and follow-up recommendations, along with providing detailed information on “how and when to test for new or returning cancers, managing side effects, making healthy lifestyle changes, and coordinating care among primary care providers and specialists.”2 Nurses can use this to brush up on current knowledge and treatment standards.

Caring for patients with head and neck cancer can bring a variety of challenges for both patients and providers. Improving quality of life in survivorship focuses on several aspects of patient care, including providing support for development of appropriate coping mechanisms and skills, education regarding lifestyle risk factors, collaboration of ongoing care, and management of individual long-term goals. Healthcare professionals are advised to practice self-care when providing assistance to this complex population, as it is critical to ensure these patients continue receiving dignified and compassionate care throughout their arduous healthcare journey.

As a nurse educator, O’Leary enjoys supporting others in the profession, as well as seeing their involvement. “I have gotten to where I am today because people mentored and supported me,” she says. “I love paying that forward, showing them what they can do.”

ACS releases long-term care guideline for survivors of head and neck cancer. American Cancer Society website. cancer.org/latest-news/acs-releases-long-term-care-guideline-for-survivors-of-head-and-neck-cancer.html. Published March 22, 2016. Accessed February 24, 2018.

Head and neck cancer—patient version. American Cancer Society website. cancer.gov/types/head-and-neck. Accessed February 23, 2018.

Cover Story

Colleen O’Leary, MSN, RN, AOCNS, teaches nurses how to employ compassion and professionalism to improve quality of life for survivors with complex challenges.