Technology has revolutionized healthcare, making it safer and more accessible than ever. Smart pumps deliver intravenous medications. Electronic health records influence decision support. Remote pharmacists and video conferencing services connect clinicians with resources and information from professionals across the globe. Researchers partner with artificial intelligence programs for developing new drugs, predicting tumor evolution, and distinguishing types of cancer cells. Technology has become an indispensable component of modern healthcare.

Technology has also revolutionized patient access to healthcare tools that can make it easier for people to manage care at home. Conduct a Google search for “cancer apps” and instantly you have many options—care advisers, medication trackers, symptom checkers, support groups, treatment reminders, memory boosters, insomnia busters, meditation guides, and audio diaries are all available with a simple point and click. When it comes to healthcare help, there really is an app for that. Thanks to technology, nurses, researchers, and patients have more options and access than once thought possible.

Along with those technological advances come changes in care delivery. At-home symptom monitoring is rapidly becoming a reality, and for patients with cancer, novel technologies can improve quality of life by putting more power in their hands. As cancer care increasingly takes place in outpatient settings, the complex task of managing the effects of chemotherapy creates a heavy burden for patients. Despite the best efforts of oncology nurses and other clinicians to ensure that patients have the information they need to manage nausea, insomnia, pain, loss of appetite, and other debilitating symptoms, patients frequently end up in the emergency department or are admitted to the hospital because they didn’t know what to do regarding an adverse event or when to act.

Kathi Mooney, PhD, RN, FAAN, is a distinguished professor of nursing at the University of Utah and coleader of the Cancer Control and Population Sciences Program at Huntsman Cancer Institute in Salt Lake City. In a recent interview with 

, she spoke about how one new technology, SymptomCare@Home (SCH), can significantly reduce symptom burden.

“SCH relieves patients of the need to remember instructions they received days or weeks ago. Instead, they’re reminded immediately when reporting a problem, such as nausea,” Mooney said. “They don’t need to know the sequence of what they should do or remember where they put their folder of information. They hear what they need to do when they need to do it.”

The tandem of automated coaching and provider response follows a stepped approach to symptom management, Mooney said. Patients access the system via a web-based platform or mobile application or by telephone. Using a complex algorithm, SCH assesses patient symptoms according to type, severity, and frequency.

Then, based on patient input, the app provides tailored coaching. With nausea, for example, patients are asked if they’ve taken antinausea medication regularly and, if not, why not. In addition to providing on-the-spot instructions, this assessment and coaching technology can help guide discussions in clinic and prompt provider adjustments to plans of care as needed.

Results of a study on the effectiveness of SCH showed that patients in the intervention group had significantly better symptom management than those in the usual care group.

 The platform is user-friendly, specific to patient needs, and immediately responsive, which helps patients manage their care more independently and efficiently. Although SCH has thus far been used for research purposes only, programmers are readying the system for integration into clinical practice at Huntsman Cancer Institute this summer. Mooney said they are willing to work with providers interested in the technology.

“Altering the coaching to fit a specific approach doesn’t require a specialized programmer,” she said.

Other novel symptom support and management technologies are being developed, and the possibilities for future innovation seem limitless. One promising prototype for patients with cancer aims to detect severe neutropenia through optical imaging of nail-fold microcirculation.

 This technology is in its infancy, but developers hope that one day portable units will quickly, effectively, and noninvasively identify life-threatening white blood cells counts earlier on.

Disease-specific innovations are also making headway, such as the Personal Patient Profile— Prostate (P3P) application, which aims to ease decisional conflict regarding treatment options using an internet-based support system.

 The system incorporates individualized coaching through text and video education. Studies have demonstrated that P3P aids patient decision making for prostate cancer treatment.

The iCancerHealth app is yet another symptom assessment and management tool that complements in-clinic patient education by instructing patients on how to conduct self-assessments, self-administer medications, and manage symptoms.

 The goal of this and many of the novel technologies in the works is to empower patients to better manage their care, which in turn will improve quality of life, reduce the need for emergency care and hospitalization, and intervene early on when intensified care is needed.

Oncology nurses are positioned to influence these technology advances by staying informed, participating in the development of clinically sound algorithms, advocating for implementation of strategies that improve patient care, and embracing the benefits they offer.

Mooney KH, Beck SL, Wong B, et al. Automated home monitoring and management of patient-reported symptoms during chemotherapy: results of the symptom care at home RCT. 

2017;6(3):537-546. doi: 10.1002/cam4.1002.

Bourquard A, Pablo-Trinidad A, Butterworth I, et al. Non-invasive detection of severe neutropenia in chemotherapy patients by optical imaging of nailfold microcirculation. 

2018;8(1):5301. doi: 10.1038/s41598-018-23591-0.

Berry DL, Hong F, Halpenny B, et al. Decision support with the Personal Patient Profile-Prostate: a multicenter randomized trial. 

2018;199(1):89-97. doi: 0.1016/j.juro.2017.07.076.

Berry DL, Blonquist TM, Nayak MM, Grenon N, Momani TG, McCleary NJ. Self-care support for patients with gastrointestinal cancer: iCancerHealth. 

2018;9(4):833-340. doi: 10.1055/s-0038-1675810.

Articles

Feature Story

Smartphone apps and other technological advances are helping patients to track and manage their cancer symptoms.

Novel Technology Helps Patients Manage Symptoms

The FDA expanded the indication for for pemetrexed (Alimta) injection plus pembrolizumab (Keytruda) and platinum-based chemotherapy for the first-line treatment of patients with metastatic nonsquamous non—small cell lung cancer (NSCLC) without EGFR or ALK alterations.

The decision was based on data from the phase III KEYNOTE-189 trial.

 In the double- blind study, 616 patients with advanced or metastatic nonsquamous NSCLC, regardless of PD-L1 expression and who were not EGFR or ALK positive, were randomized 2:1 to receive pembrolizumab plus pemetrexed and either cisplatin or carboplatin (n = 410) or chemotherapy alone (n = 206).

Pembrolizumab plus chemotherapy in the first-line setting reduced the risk of death by 51% in patients with NSCLC without EGFR or ALK mutations. The median overall survival (OS) was not reached in the pembrolizumab arm compared with 11.3 months (95% CI, 8.7-15.1) in the chemotherapy-alone arm. At a median follow-up of 10.5 months, estimated 12-month OS rate was 69.2% (95% CI, 64.1- 73.8) in the pembrolizumab arm versus 49.4% (95% CI, 42.1-56.2) in the control arm (HR, 0.49; 95% CI, 0.38-0.64; P <.001).

The study met the coprimary endpoint of progression-free survival (PFS), with a median PFS of 8.8 months (95% CI, 7.6-9.2) in the pembrolizumab group compared to 4.9 months (95% CI, 4.7-5.5) in the control arm (HR, 0.52; 95% CI, 0.43-0.64; P <.001).

Pembrolizumab was administered as a 200- mg fixed dose every 3 weeks, with 500 mg/m2 of pemetrexed plus 75 mg/m2 of either cisplatin or carboplatin (area under the concentration curve, 5) on day 1 every 3 weeks for 4 cycles, followed by 200 mg of pembrolizumab plus 500 mg/m2 of pemetrexed every 3 weeks. The control arm’s regimen was identical, with placebo instead of pembrolizumab.

Patient characteristics were well balanced between the 2 arms. The median age was 65 years in the pembrolizumab arm, 62.0% of the patients were men, and all but 1 of the patients had an ECOG performance status of 0 or 1. Current and former smokers made up 88.3% of the cohort, and 96.1% of patients had adenocarcinoma.

Additional results showed that the OS benefit with pembrolizumab was observed across PDL1 subgroups, including the <1% expression group (12-month OS rate, 61.7% vs 52.2%; HR, 0.59; 95% CI, 0.38-0.92); the 1% to 49% cohort (12-month OS rate, 71.5% vs 50.9%; HR, 0.55; 95% CI, 0.34-0.90), and those with expression ≥50% (12-month OS rate, 73.0% vs 48.1%; HR, 0.42; 95% CI, 0.26-0.68).

The objective response rate per blinded, independent central radiologic review was 47.6% (95% CI, 42.6-52.5) in the pembrolizumab arm and 18.9% (95% CI, 13.8-25.0) with chemotherapy alone (P <.001). The disease control rate was 84.6% versus 70.4%, and the median duration of response was 11.2 months versus 7.8 months in the pembrolizumab versus control arms, respectively.

Discontinuation rates of all study drugs due to adverse events (AEs) was 13.8% in the pembrolizumab arm versus 7.9% in the control arm. The discontinuation rate of pembrolizumab was 20.2%; of placebo, 10.4%. Death related to AEs occurred in 6.7% versus 5.9% of the pembrolizumab versus control arms, respectively.

Diarrhea (30.9% vs 21.3%) and rash (20.2% vs 11.4%) were the only 2 AEs occurring in ≥10% of patients that occurred more commonly in the pembrolizumab arm. Grade ≥3 AEs that occurred in ≥10% of patients in either arm were anemia (16.3% with pembrolizumab vs 15.3% in the control group) and neutropenia (15.8% vs 11.9%, respectively).

The rate of acute kidney injury was 5.2% in the pembrolizumab arm versus 0.5% in the chemotherapy-alone arm. Eight patients (2.0%) receiving the PD-1 inhibitor had grade ≥3 acute kidney injury.

Immune-mediated AEs occurred in 22.7% of the pembrolizumab arm versus 11.9% of the control arm, including grade ≥3 AEs in 8.9% versus 4.5%, respectively. Pneumonitis led to 3 deaths in the pembrolizumab cohort. 

1. FDA Expands Lilly's ALIMTA (pemetrexed) Label with Combination of KEYTRUDA (pembrolizumab) and Platinum Chemotherapy for the First-Line Treatment of Metastatic Nonsquamous Non-Small Cell Lung Cancer. Eli Lilly & Company. Published January 31, 2019. https://bit.ly/2JfuTA6. Accessed January 31, 2019.

2. Gandhi L, Rodgríguez-Abreu D, Gadgeel S, et al. KEYNOTE-189: Randomized, double-blind, phase 3 study of pembrolizumab (pembro) or placebo plus pemetrexed (pem) and platinum as first-line therapy for metastatic NSCLC. Presented at 2018 AACR Annual Meeting; April 14-18, 2018; Chicago, Illinois. Abstract CT075.

3. Gandhi L, Rodgríguez-Abreu D, Gadgeel S, et al. Pembrolizumab plus chemotherapy in metastatic non—small-cell lung cancer. N Engl J Med. 2018;378:2078-2092.

Updates

The FDA expanded the indication for for pemetrexed (Alimta) injection plus pembrolizumab (Keytruda) and platinum-based chemotherapy for the first-line treatment of patients with metastatic nonsquamous non–small cell lung cancer (NSCLC) without EGFR or ALK alterations.

Pemetrexed Approval for Frontline Pembrolizumab/Chemo Combo in NSCLC Gets Expansion

The FDA recommends that no new patients with advanced soft tissue sarcoma (STS) be treated with olaratumab (Lartruvo) plus doxorubicin, following the negative results of the phase III ANNOUNCE trial.

The agency’s statement follows the January 2019 announcement that olaratumab in combination with doxorubicin missed the trial’s primary endpoint of overall survival (OS) and did not confirm a clinical benefit for patients with advanced or metastatic STS compared with standard doxorubicin.

 The OS endpoint in the leiomyosarcoma subpopulation also was not met.

“[T]he FDA recommends that patients who are currently receiving Lartruvo should consult with their healthcare provider about whether to remain on the treatment,” the FDA stated in a press release. “The FDA also recommends that Lartruvo should not be initiated in new patients outside of an investigational study.”

According to the statement, patients currently receiving olaratumab may continue to receive the treatment if they appear to be benefiting from it.

Results of ANNOUNCE (NCT02451943), which was the confirmatory trial for the FDA olaratumab’s approval in this setting, showed no difference in OS between the 2 arms. The median OS was 20.4 months with olaratumab/doxorubicin and 19.7 months with doxorubicin (HR, 1.05). In the leiomyosarcoma subpopulation, the median OS was 21.6 months and 21.9 months for olaratumab/doxorubicin and doxorubicin alone, respectively. The median PFS with olaratumab/doxorubicin was 5.4 months and 6.8 months with doxorubicin alone (HR, 1.23).

Olaratumab was well tolerated, and no new safety signals were reported. Eli Lilly stated in a press release that the phase III data do not support starting patients on the therapy outside of a clinical trial.

1. FDA grants accelerated approval to new treatment for advanced soft tissue sarcoma. FDA. Published October 19, 2016. Updated January 24, 2019. https://bit.ly/2CO8eVd. Accessed January 24, 2019.

2. Lilly Reports Results of Phase 3 Soft Tissue Sarcoma Study of LARTRUVO®. Eli Lilly and Company. Published January 18, 2019. https://bit.ly/2RXHz1W?rel=0" . Accessed January 18, 2019.

Clinical Trials in Progress

The FDA recommends that no new patients with advanced soft tissue sarcoma (STS) be treated with olaratumab (Lartruvo) plus doxorubicin, following the negative results of the phase III ANNOUNCE trial.
 

FDA Advises Against Starting Olaratumab for Soft Tissue Sarcoma

Cancer and its treatments can bring a number of adverse events (AEs), and as more patients are living longer after their treatment, these effects can become long-lasting. Often, oncology nurses are the first line of defense in communicating with patients about how they are feeling.

Matthew Carlson, MD, an assistant professor at The University of Texas Southwestern Medical Center, recently sat down with 

®, to discuss the longterm effects that chemotherapy and other cancer treatments can have on individuals.

®: What can healthcare providers do to better manage patient depression?

 I think it’s important to have a high index of suspicion. The NCCN [National Comprehensive Cancer Network] guidelines recommend screening patients who are in surveillance for depression. So, you should ask them, “On more days than not, have you had low mood or trouble sleeping or basic depressive symptoms?” And those simple screening questions can then prompt us to dig a little deeper and, hopefully, help the patient with the depression, because that can have longterm effects, as well.

Do you feel that this is being done often enough?

The answer to that is, unfortunately, probably not. We probably don’t screen just because we see the surveillance patient [and] we ask them how they’re doing, and unless they bring it up—at least for me personally&mdash;I don’t do it as often as I should, I’ll admit. But it’s something that I’ve paid more attention to, and we’ve considered adding some screening questionnaires to our practice.

What are the glaring challenges here in terms of symptom management?

It’s a chronic thing. It’s very bothersome [for patients with neuropathy] to have constant pins and needles in the hands and feet. There’s even numbness, where patients can have trouble doing activities of daily living, such as fastening buttons or putting in earrings and things of that nature. That really becomes somewhat troublesome, and it can even become dangerous if they have a lot of numbness in their feet and don’t feel the ground under their feet and then are subject to falling.

It is a big issue, and, unfortunately, not a lot is being done. I think [investigators] are actively looking at different agents to decrease the risk—things that we can give during chemotherapy to reduce the incidence of adverse events during chemotherapy and, therefore, would very likely decrease it after as a long-term adverse event. But progress has been slow.

Adverse Events Report

Oncology nurses are often on the frontline when it comes to talking to patients about how they are feeling.

Treatment of Depression and Fatigue in Cancer Survivors Needs Improvement

Rapid changes occurring nationally and worldwide—including shifts in demographics, languages, epidemiological patterns, and social systems&mdash; have direct implications for patient care. These trends are projected to continue, and nurses need to be prepared to care for increasingly diverse patient populations.

Despite increased knowledge on preventing and treating cancer, the incidence of the disease is rising in developing countries. Cultural practices play an important role with respect to cancer care.1 For example, rates of head and neck cancers are particularly high in regions of the world where tobacco use and alcohol consumption is high.

Culture is the learned, shared, and transmitted knowledge of a particular group’s values, beliefs, and lifeways that is transmitted intergenerationally and influences thinking, decisions, and actions.2 Sound knowledge of diverse cultures helps strengthen the nurse—patient relationship. Nurses must understand cultural practices in order to support patient-centered, quality care, and safe outcomes for all patients with cancer.

The context of South Asian countries can be used to illustrate how nurses can deliver culturally competent care through improved knowledge of the perceptions of health and illness. Among these cultures, health is usually related to the connectedness of the body, mind, and spirit. Traditionally, most people who are elderly focus spiritually on preparing the soul for life after death. In South Asian culture, individuals who are sick may promise gifts to a temple god if they recover. Gender and geography are also salient. In rural communities in India, women may remain quiet about their health problems and delay seeking care, whereas in urban areas, women may be more likely to seek screening.

Admission assessment presents the optimal time to explore cultural needs and practices. Immigrants who do not speak English may need an interpreter to facilitate the assessment. It may be helpful for providers to know that patients who are elderly may not prefer the option of counseling for problem resolution. Therefore, at the time of admission, it is important that nurses ask if patients are receptive to counseling, because getting the news of a cancer diagnosis may put patients in a situation of refusing counseling regarding treatment options later on.

Other considerations may be more subtle. For example, refusal to wear a hospital gown may have a religious basis: Some patients do not like to wear clothing others have worn, even though it has been washed and sterilized. Providers also may not know that a mangalsutra, a thread Hindu women wear a thread around their necks, should not be removed during an exam without the patient’s permission.

When nurses educate patients from India about fasting before procedures, they should discuss the status of “nothing by mouth” by clarifying the term “fasting.” Among elderly Indian women, fasting is a common practice based on a religious belief that it improves the welfare of the family. However, sometimes fasting allows consumption of water and fruits. Healthcare providers should respect these practices if the patient’s medical condition can tolerate it.

Dietary needs also should be clarified at the time of admission. Hospital food can be a problem for patients who strictly observe dietary restrictions. Beef is forbidden for Hindus; others are pure vegetarian and do not like to discuss meat. Culture also affects discharge planning. In South Asian culture, care coordination with social workers and home care nurses is not common practice. Social stigma is attached to placing an older person in a nursing home, and therefore, people often do not like to discuss this option. Every patient with cancer deserves culturally competent care. Nurses should take a leading role in ensuring that appropriate care is provided, working in a flexible way with the multidisciplinary team to serve diverse patient populations, beginning with the assessment intake and continuing throughout treatment and discharge planning.

Saca-Hazboun H, Glennon CA. Cultural influences on health care in Palestine. 

2011;15(3):281-286. doi: 10.1188/1CJON.281-286.

Transcultural Nursing: Concepts, Theories, Research, and Practice.

Evatt M, Lockhart JS. Thinking beyond the traditional admission assessment for patients with head and neck cancer: attention to culture. 

Note: All the authors are affiliated with Duquesne University. 

Partner Perspectives

Rapid changes occurring nationally and worldwide&mdash;including shifts in demographics, languages, epidemiological patterns, and social systems&mdash; have direct implications for patient care. These trends are projected to continue, and nurses need to be prepared to care for increasingly diverse patient populations.
 

Nurses Must Adapt to Meet the Needs of a Diverse Patient Population

A cancer diagnosis brings many concerns to a patient’s mind, from the practical issues surrounding treatment and living with cancer to existential thoughts about mortality, legacy building, and what suffering or growth one might experience. Grappling with these challenges and changes and, at the same time, struggling with a basic bodily function— to have normal bowel movements&mdash;adds an unnecessary burden that diminishes the quality of life for our patients.

Despite the extensive literature and practice guidelines

 that exist to manage constipation, this symptom is far too common; 60% of adult patients with cancer are constipated, as are up to 90% of patients with cancer taking opioids.

 Nurses are instrumental to ensuring that a patient’s symptoms are assessed and managed to promote well-being, and patients with cancer who are experiencing constipation deserve our attention.

For patients with cancer, the many risk factors for constipation can be classified as organic, functional, or drug induced.

 Organic causes of constipation often involve electrolyte abnormalities, neuropathies or myopathies, other diseases such as diabetes or Parkinson disease, and structural issues (eg, related to radiation or masses). Functional causes include decreased activity, reduced water or fiber intake, lack of privacy, and pain during defecation. Common categories of medications causing constipation are opioids, chemotherapy (alkylating agents, vinca alkaloids), antiemetics (5-HT3 receptor antagonists), antidepressants, anticholinergics, antacids, antihypertensives, diuretics, and iron-containing supplements.

Given the known symptom prevalence and risk factors above, can you think of a patient with cancer who should not be assessed for constipation?

Constipation is defined as incomplete defecation and/or infrequent bowel movements that are associated with persistent difficult and/or painful defecation, fecal incontinence, and abdominal pain.

A common tool for assessing constipation is the Rome III diagnostic criteria, in which a patient meeting any of these 2 symptoms for 12 or more weeks in the past year is considered to have functional constipation:

• Sensation of rectal blockage or obstruction

Other tools for assessing constipation exist, and there is no universally agreed-upon instrument to use in clinical practice. The criteria used should address the date of the patient’s last bowel movement, frequency of bowel movements, consistency of stool, recent changes in bowel patterns, the urge to defecate, sensation of evacuation, fecal incontinence, evidence of blood or mucus in the stool, current or previous laxative use, and the need for digital manipulation to facilitate evacuation.

Physical exam focuses on visualization of the abdomen, auscultation of bowel sounds, palpation, and a rectal exam. Contraindication to rectal exams include neutropenia and thrombocytopenia.

If a patient is prescribed medications known to cause constipation, the nurse must advocate for preventative measures. Some nonpharmacologic interventions include increasing water intake, consuming foods high in soluble fiber, and getting physical exercise.

When a patient is taking opioids, nurses should also advocate for pharmacologic intervention to prevent opioid-induced constipation. Recommended pharmacologic interventions can usually start with a stimulant laxative like oral senna (Senokot).

Nurses can also advocate for increased roughage (found in high-fiber foods such as fruits, vegetables, dried fruits, and oatmeal) and increased fluid intake. The barriers to these suggestions may be that the patient may be experiencing anorexia, taste changes, or a decreased ability to consume adequate fluid intake.

Nurses have an opportunity to champion the assessment and management of constipation, which causes distress and discomfort for so many patients with cancer. What elements of your practice could change to promote consistent and thorough assessment for constipation? Could the algorithm shared here be implemented in your practice setting?

Tian H, Ding C, Gong J, et al. An appraisal of clinical practice guidelines for constipation: a right attitude towards to guidelines. 

. 2016;16(1):52. doi: 10.1186/s12876-016-0466-8.

Wickham RJ. Managing constipation in adults with cancer. 

Larkin PJ, Cherny NI, La Carpia D, et al. Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. 

. 2018;29(suppl 4):111-125. doi: 10.1093/annonc/mdy148.

Fast Facts for the Frontline

About 60% of adult patients with cancer experience constipation, but oncology nurses can help.

Managing Constipation in the Cancer Care Setting

One of the unique aspects of oncology nursing is our ability to be present during some of the most dark times patients face. Through this, we develop relationships that lead to meaningful connections and trust. Our patients will come to us and trust us to speak the truth, as well as seek a safe place where they can share their darkest and deepest secrets and concerns.

Being present requires the ability to engage in conversations that ensure patients’ goals of care align with their priorities. This is not easy. Additional education and skills are required to master these discussions in a way that provides the desired result.

Palliative care focuses on caring for patients living with a serious illness and also supports their families. Unlike hospice care, which is given when treatment stops and usually takes place within the last 6 months of life, palliative care can start at the time of diagnosis. Both specialties address the symptoms and emotional aspects of care. Lack of access to specialty palliative care is a constant challenge for patients with cancer across the United States. Access in rural hospitals is even more challenging because of the lack of training, resources, and specialty palliative care clinicians. Although many rural health systems seek to provide elements of palliative care, including patient and symptom management and advance care planning, many local clinicians and nurses offer these services in the absence of formal training or specialty certification.

Today, many health systems struggle with providing quality end-of-life care. Thirty percent of all Medicare dollars are spent on end-of-life care.

 Often, treatment increases suffering and fails to improve the quality of life. As a result, institutions are beginning to see the benefit of incorporating palliative care earlier in the disease process, in part because of research findings that reflect this. However, they struggle with determining which model will prove to be the most sustainable.

Unfortunately, this is a common problem without easy answers. Institutions are looking for innovative models that can help ensure that patients and staff have critical resources needed to deliver quality patient care. An example of how 1 health system is addressing this challenge is seen in the Conversation Nurse Model. This program provides nurses with the training required to have serious illness discussions, as well as goals for care, and an interdisciplinary team provides hospice and palliative care consults. Initial data reflect the following cost savings benefits:

• Increase in number of palliative care consults for inpatients

• Increase in number of patients with advance directive

• Increase in hospice consults for patients in skilled nursing facilities • Decrease in readmission

• Expansion of trained staff to increase education into the community

Nurses often find themselves in a position to lead improved end-of-life care within their own institution. Often, a simple survey to physicians and staff can help identify their perception of how care is delivered and opportunities for improvement. Another example may be setting up processes so that patients are asked if they understand advance directives. This would be an opportunity to provide important education before patients and caregivers are faced with a crisis. Nurses should stress the importance of patients understanding the need to determine who will speak on their behalf if they are unable to do so.

As new initiatives are developed, it’s important to recognize the emotional energy required for difficult conversations. Finding support both inside and outside the healthcare setting is essential. Every patient relationship can affect nurses differently. Mindful meditation can help manage stress or anxiety, as can reflective journaling. Nurses should find people to talk with without judgment. At the end of the day, these patient experiences remind us about the finality of life and how precious each day is. Caring is a privilege, but it does come with a cost.

An example of an innovative model to improve end-of-life care is seen at High Point Regional Health System in North Carolina. The hospital identified the opportunity for improved care at the end of life. A team was brought together that initially included a surgeon, a chaplain, a nurse navigator, a hospice liaison, and a social worker. That led to developing an end-of-life care consult team led by the chaplain and the nurse navigator. A set of routine comfort orders was implemented for patients admitted to the hospital for pain and symptom management at the end of life, which resulted in an increase in advance directives and hospice referrals. Ultimately, the American Hospital Association recognized this work with the Circle of Life Award.

Difficult conversations require nurses to draw on their own skills and the skills of others to help patients and caregivers prepare for what is to come, especially if that means end of life. These conversations require time and rarely can be accomplished in 1 visit or encounter. Patients must be given the time to express what they want, how they want to live, and what is important to them. They need to understand that this is about having the quality of life they want and that stopping treatment does not mean stopping care. Providing guidance and a clear understanding of what hospice is and what it is not can help bring additional support. Giving families permission to have these conversations and ask questions may end up being one of the most important gifts nurses can offer.

Davis MA, Nallamothu BK, Banerjee M, Bynum JP. Identification of four unique spending patterns among older adults In the last year of life challenges standard assumptions. 

Lally K, Rochon T, Roberts N, McCutcheon Adams K. The conversation nurse model: an innovation to increase palliative care capacity. 

 2016;18(6):556-563. doi: 10.1097/NJH.0000000000000294.

Professionally Speaking

Talking with patients about palliative and hospice care is not always easy, but it is important.

Oncology Nurses Must Navigate Difficult End-of-Life Discussions

From advancements in treatment to new ways to monitor adverse events (AEs) and symptoms, the world of oncology is constantly changing. Although it is important that oncology nurses keep up with the evolving cancer space, there is also opportunity for them to spark change in the field.

In this issue’s cover story, we explore r

esearch opportunities for oncology nurses in radiation

, a type of therapy that benefits about 60% of patients with cancer. You will hear from nurses who led research to better understand the AEs that come with radiation to treat gynecologic cancer, as well as others who are pioneers in the field. Because nurses bridge the gap between advocate and provider, they are in the perfect position to recognize patients’ needs and seek solutions for those undergoing radiation therapy.

Also in this issue, we discuss novel technologies—from smartphone apps to web-based programs&mdash;that are becoming increasingly popular in the management of AEs. As patients look more toward home monitoring of their symptoms, oncology nurses must understand how to interpret the data and still ensure that patients get the proper care that they need. Finally, our continuing education (CE) section focuses on some of the exciting advancements that were presented at the 2019 Genitourinary Cancers Symposium. Read the articles and nurse perspectives, and don’t forget to log on to OncNursingNews.com to take a quiz and receive 1 CE credit hour.

®, we constantly strive to bring oncology nurses the latest information to improve their practice. We hope that you find this issue, too, to be useful and inspiring.

From the Chairman

Because nurses bridge the gap between advocate and provider, they are in the perfect position to recognize patients’ needs and seek solutions for those undergoing radiation therapy. 

Nurses Must Keep Up With Cancer Care's Constant Change

Nurses often ask me which sessions they should attend when going to an oncology nursing conference, but there is no standard reply. It takes some homework to ensure that they get the most out of their conference experience. They should tailor their plan as much as possible. For example, nurses should consider if the topic of a session is unfamiliar to them and something they want to learn more about. Is the focus an issue that is causing struggles at work? Is it a peripheral theme that does not directly affect current nursing practice but likely will in the future?

Over the decades, I have attended hundreds of conferences. Because of my extensive track record in continuing education, I have some thoughts about what nurses should consider before day 1 of an event.

First, scrutinize the schedule. Highlight the titles that seem appealing. Then, if available, look at the session descriptors and goals. Knowing this information might influence the decision to attend or not. Lastly, consider the speaker. Is this a recognized opinion leader on the topic? Have they written about the theme of the session? Ask colleagues who have attended similar offerings if they have heard that person present. If so, did the speaker connect with the audience, provide practical information—not just read the slides&mdash; and offer new information of relevance to the participants? All these components are critical musts to maximize learning.

Second, look for offerings that are different from the typical didactic session. There is only so much a person can absorb when someone else does all the talking and you do the listening. Is there evidence in the brochure that the presenters will use videos, role-playing, small group sessions, case studies with an audienceresponse format, or other types of novel teaching methods? Engagement is the key factor here.

Third, before attending the conference, be sure to check the listing about the availability of handouts and copies of slides. Get these in order before departing for the conference. I put these materials in a binder arranged by the day so that I am organized at the outset. It’s also important to bring several highlighters and take notes liberally. When listening to a lecture, I often find myself triggered to consider something new or am made aware of a related concept. For example, I was listening to a talk on neuro-oncologic emergencies, and much of the information being presented focused on seizure management and cognitive changes. I found myself thinking, “What about patients driving? Are there criteria to consider in offering advice about

Fourth, don’t assume that a major conference won’t give attendees an opportunity to share their views. Look for roundtable discussions and opinion panels for which the audience is asked to contribute. Many times, these interactive formats are the most informative. Also, the networking that transpires can be invaluable. Ask for new colleagues’ contact information. Look for opportunities to increase your peer network. At lunch, look for unfamiliar faces and sit at that table. At social events, try an introduction such as “I think I saw you in the town hall meeting. What did you think when they said…?” Following a particularly impressive or enjoyable session, approach the speaker to find out if he or she is open to being contacted later.

Attending a major conference provides the opportunity to look outside your own little box. Your world expands. You are on the receiving end of new information and become enlightened. You feel validated when you hear that you are doing a procedure in the ideal manner. More than once, I have heard colleagues say something along the lines of “Well, we’ve been doing that for a year now.” You may also be energized to prepare an abstract for a future conference.

Lastly, I know participants frequently get tired of hearing about the importance of filling out evaluations, but this step is critical. Conference planners look at the evaluations closely. Attendees’ opinions are heard, especially when they offer suggestions to improve an element of the education. Taking action to better the offering affects future attendance and, ultimately, revenue.

I challenge nurses to change their way of thinking about conference attendance. It requires more than a passive stance of showing up, sitting for long periods of time, and listening. To maximize conference participation, take an active role in analyzing, synthesizing, and configuring the educational experience based on your individual learning needs. Enlightenment is worth it.

Nurse's Notes

Five tips on how oncology nurses can maximize the benefits of meeting attendance.

Plan Ahead to Get the Most Out of Conferences

Deborah Watkins Bruner, PhD, FN, FAAN. - Photo credit Bailey Davidson

Patients with cancer often struggle as a result of radiation side effects. Dorothy Pierce, DNP, NP-C, CRN, CBCN, CLT, an advanced practice nurse in radiation oncology at Rutgers Cancer Institute of New Jersey in New Brunswick, understands this well.

Approximately 60% of patients with cancer benefit from radiation, which is used either on its own or in conjunction with chemotherapy.

 But along with its ability to kill cancer cells and shrink tumors, radiation therapy can cause treatment- related adverse events (AEs).

As patient advocates and educators, Pierce says, radiation oncology nurses have the unique opportunity to not only care for patients undergoing radiation therapy but also get involved in related research that improves patient care. With the field of radiation therapy rapidly growing, there is a need for more nursing innovation, according to Pierce. “Many nurse practitioners [NPs] are becoming involved in radiation oncology, and some are working as coinvestigators on quality-of-life studies with radiation oncologists,” Pierce says. “Because nurses are at the forefront of patient care, they can help improve practice guidelines.”

Last year, Pierce and her colleagues examined best practices for preventing vaginal stenosis, which causes abnormal tightening and shortening of the vagina. The condition is a common AE of pelvic radiation therapy or brachytherapy treatment for uterine, cervical, and vaginal cancers and affects about a third of women who undergo the procedure.

Pierce conducted a phone survey in 6 New Jersey counties, talking with advanced practice nurses, registered nurses, and a brachytherapyfocused therapist, all of whom worked in radiation oncology programs. Healthcare practitioners were asked whether they counseled their patients on vaginal stenosis.

Survey results showed inconsistent practices in educating patients about the condition. Also, advanced practice nurses were underused in advising patients on best practices for managing and preventing vaginal stenosis, such as the use of vaginal dilators.

“[Although] not life-threatening, vaginal stenosis can result in long-term sexual dysfunction and painful vaginal examinations,” Pierce says. “Advance practice nurses are on the frontlines, helping to educate patients, pursue research opportunities, and implement quality improvement projects.”

Pierce began her own career as a primary radiation oncology nurse before going on to obtain her doctor of nursing practice (DNP) degree. “There are so many opportunities for nurses to make a difference in radiation therapy,” she says.

“Skin-care issues is an area where there are many inconsistencies in the guidelines, and [although] there are many creams that can help to relieve discomfort, they don’t prevent skin issues.”

Anxiety and depression are also common among patients who undergo radiation therapy, and this issue doesn’t receive enough attention, according to Pierce. “Patients often become depressed at the thought of their cancer returning,” she says. “Nurses play a critical role in identifying and managing each patient’s symptoms and ensuring they are linked to appropriate care.”

Deborah Watkins Bruner, PhD, RN, FAAN, senior vice president of research at the Winship Cancer Institute at Emory University in Atlanta, Georgia, is considered a pioneer in oncology nursing research and cancer clinical trials. Her areas of focus include sexuality after cancer therapy, patient-reported outcomes, and symptom management for patients receiving radiation therapy.

“Nurse research should lead to or influence evidence-based patient care guidelines,” Bruner says. “There’s a plethora of data in radiation therapy research, but we need to have more nurses implementing the information in real time to help patients better manage symptoms.”

Bruner’s career path took a turn toward research when she was working as a clinical nurse specialist in gynecologic nursing. “I became frustrated at the lack of evidence for managing symptoms of gynecologic cancer,” Bruner says.

“Historically, there has been little attention on how radiation therapy and other treatments can affect a woman’s quality of life and sexual function after treatment for ovarian, cervical, and endometrial cancers.”

After earning 2 master’s degrees, 1 in oncology and 1 in nursing administration, Bruner decided to return to school to earn her PhD and pursue a career in research. She is the only nurse to lead a National Cancer Institute-sponsored National Clinical Trials Network cooperative group, the NRG Oncology National Community Oncology Program.

Many possibilities exist for nurses to move into radiation oncology research and be involved in writing policy- or evidence-based research, Bruner says. “There’s a tremendous opportunity for clinical oncology nurses, nurse practitioners, and nurse researchers to educate cancer patients, manage their patients’ care plan, and educate them on potential [adverse] effects,” Bruner says. “Nurses can follow a career path from staff nurse to DNP to PhD and play a significant role in the discovery and implementation of practice guidelines.”

PhDs are research-based, while DNP degrees are focused more on clinical practice.

NEW CANCER TREATMENTS REQUIRE RESEARCH ON SYMPTOM MANAGEMENT

Over the past 2 decades, radiation therapy has been increasingly used as a treatment option for patients with cancer, underscoring the need for oncology nurses to understand its impact on patients. Radiation therapy can be administered in many ways: by external beam, in which a machine delivers treatment; internally (brachytherapy), via sealed sources of radioactivity placed near or within the tumor; and, less commonly, by liquids taken orally or infused through a vein (systemic infusion).

Robotic systems such as CyberKnife, an advanced lightweight linear accelerator, mounted on a robotic arm, delivers an intense focused dose of radiation to the targeted tumor. Another treatment, stereotactic body radiation therapy, involves very high doses of radiation using several beams of various intensities aimed at different angles to precisely target the tumor.

“The changes in the treatment are driving oncology nursing care from supportive care for patients receiving radiation therapy to the primary care providers during radiation therapy,” says Jessica Liu, RN a clinical research nurse at City of Hope in Duarte, California.

Additionally, advancements in radiation therapy are leading to changes in how patient care is managed. For example, Liu says, a new, FDA-approved radioisotope IV radiation therapy, Lutathera, is used to treat gastroenteropancreatic neuroendocrine tumors. Until recently, patients with this condition had few treatment options.

“In addition to recent developments in therapeutic areas, radionuclide materials are also being studied in the diagnostic field,” Liu says.

Liu cites many studies that combine radionuclide with diagnostic scans to determine if physicians can visualize the disease beyond what current technologies provide. Several studies combine radioisotope and machine-targeted radiation therapies to manage certain cancers and explore more promising disease treatments.

“Apart from the radionuclide approach, MRI [magnetic resonance imaging]—guided focused ultrasound is an existing technology used to treat certain cancers, and the results are encouraging,” Liu says. “This technology is being further developed to manage other types of cancers in different research phases.”

As radiation treatments evolve, the nurse’s role also expands to include both teaching and caregiving, showing patients how to effectively manage AEs. “Radiation exposure is a concern for many patients,” Liu says. “However, proper information and education before the therapy can help decrease patients’ anxiety.”

Many patients with cancer also undergo combined modality care, such as immunotherapy drugs used in conjunction with radiation therapy to treat advanced cancers. Nurses who work in radiation oncology will need to educate patients about the possible risks and symptoms associated with radioimmunotherapy, Bruner says.

“We still don’t know enough about the symptom profile of precision medicine and immunotherapies. With each new therapy, there’s a new symptom profile,” Bruner says. “In addition, patient adherence, financial toxicity, and drug toxicity are all issues of concern.”

Financial toxicity is a particular worry among older patients, Bruner says. Many must undergo 4 to 6 weeks of radiation therapy but have problems related to transportation and caregiving support, which can be obstacles to receiving care.

“There’s the reported [adverse] events such as skin issues and fatigue, combined with psychosocial factors such as depression and maintaining quality of life,” Bruner says. ““Nurses who work in this area look at issues that affect patients that go far beyond cancerous tumors.”

Editor’s note: In the print edition, the subject of the cover photo was incorrectly labeled as Dorothy Pierce. The correct subject of the photos is Deborah Watkins Bruner, PhD, FN, FAAN.

National Cancer Institute. Radiation Therapy and You: Support for People With Cancer. Bethesda, Maryland. 

US Department of Health and Human Services. National Institutes of Health

https://www.cancer.gov/publications/patient-education/radiationttherapy.pdf

Morris L, Do V, Chard J, Brand AH. Radiation-induced vaginal stenosis: current perspectives. 

International Journal of Women’s Health

Velikyran I. Radionuclides for Imaging and Therapy in Oncology. 

doi.org/10.1016/B978-0-12-407722-5.00017-7

Nitipir C, Niculae D, Orlov C, et. Al. Update on radionuclide therapy in oncology. 

Cover Story

Nurses are already on the forefront of patient care, and they can lead research, too.

April 2019