		Tiffany Keller-Fritz has been cancer-free for 2 years. She is a designer for a handbag company and is working with her employer on cancer-related bag designs and chemotherapy bag covers.

	In late 2008, 36-year-old Tiffany Keller-Fritz attributed intermittent diarrhea to stress related to an impending cross-country move. With the move completed, and pregnant with her third child, Tiffany’s diarrhea had persisted for 3 months and was now occurring several times daily, symptoms her OB-GYN dismissed as simply related to her pregnancy.

	By the end of October 2009, Tiffany was experiencing extreme fatigue, severe constipation, and progressively worsening rectal pain and pressure. With her physician once again dismissive, and now 29 weeks pregnant, Tiffany found a new OB-GYN practice, where a midwife nurse practitioner palpated a mass between the rectum and vagina. Two days later, on February 26, 2010, a sigmoidoscopy with biopsies revealed squamous cell carcinoma (SCC) of the anus.

	Magnetic resonance imaging (MRI) performed on March 7 depicted a 3.1-cm x 2.9-cm x 3.2-cm anal canal tumor involving 75% of the canal’s circumference. Now nearly 34 weeks pregnant, Tiffany was referred to Tampa’s H. Lee Moffitt Cancer Center, evaluated by a team of specialists, and scheduled for a March 22 C-section. Tiffany’s daughter Riley was delivered using a low vertical incision in an attempt to avoid the anticipated field of radiation. On April 15, a positron emission tomography (PET) scan showed locally advanced (stage III) anal cancer with involvement of the left inguinal and right iliac nodes.

	Needing time to heal before undergoing pelvic radiation, but also needing to begin treatment as soon as possible, Tiffany initially underwent one round of chemotherapy with a single dose of cisplatin and a 96-hour continuous infusion of 5-fluorouracil (5-FU) administered via a pump connected to an indwelling port. Two weeks later she began concurrent chemotherapy/radiation as follows:

		Radiotherapy (30 fractions) 5 days per week for 6 weeks (total dose, 5400 cGy)

		Chemotherapy during weeks 1 and 5 of radiotherapy, with a 96-hour continuous infusion of 5-FU plus mitomycin C administered via IV push on days 1 and 2

	On May 20, an interim PET scan demonstrated a significant response to treatment and helped to determine the final radiation dose. Treatment was completed on June 3, and a third PET scan, obtained on September 14, was completely normal. Two years post-treatment, Tiffany remains cancerand colostomy-free. She will be followed with twiceyearly physical exams, blood work, and annual chest, abdominal, and pelvic CT scans. After 5 years with no evidence of cancer, she will be referred to Moffitt’s survivorship program.

	As recently as the 1970s, SCC of the anus was considered a surgical disease necessitating permanent colostomy. Fortunately, combined chemotherapy and radiation became the standard of care; initially, it was used to shrink the tumor preoperatively but was ultimately deemed curative without surgery for stage I through III disease. Today, surgical resection is generally reserved for patients for whom chemotherapy/radiation fails. Also fortunate are the advent of improved radiotherapy techniques and equipment, along with the use of PET scanning to accurately shape the radiation dose, which have greatly reduced radiation-related toxicities that, in the past, often necessitated lengthy hospital stays.

	In Tiffany’s case, the safety of her unborn child, weighed against the urgent need to initiate treatment, required close collaboration between her oncologists and OB-GYN. If not pregnant, Tiffany would have immediately undergone concurrent chemotherapy/ radiation, but healing time was needed after the C-section before pelvic radiation could safely be started. With Moffitt’s associate professor of Radiation Oncology, Sarah Hoffe, MD, reluctant to delay treatment for what was a fast-growing malignancy, and Tiffany’s OB-GYN comfortable with performing the C-section at 34 weeks, the decision was made to administer a single chemotherapy dose shortly after delivery, and then commence combined therapy after 2 weeks of healing.

	Hoffe notes that this particular combination of mitomycin C and 5-FU delivered concurrently with radiotherapy has been shown to be the most effective in preventing the need for colostomy, as was the case with Tiffany.

	Tiffany did not develop the neutropenic fever and infection sometimes associated with this regimen. She did, however, develop oral lesions that made it difficult to eat during the first round of treatment. Despite some nausea (managed with oral prochlorperazine), extreme constipation, and feelings of panic during her initial chemotherapy, Tiffany recalls having had a strong sense that the cancer had stopped growing by day 5 of treatment.

	Radiotherapy in the anal region typically causes skin desquamation and, as in Tiffany’s case, can also cause urethritis. Two weeks after Tiffany began radiation, the topical moisturizer Aquaphor was used for anal and vaginal skin irritation. As the irritation worsened and she described feeling as if she were “urinating fire and glass,” Tiffany was taught to use a sitz bath. As skin breakdown progressed, she was taught to apply Radiocare, a hydrogel-type ointment containing lidocaine, and then Silvadene, which is often used toward the end of radiotherapy to provide pain relief, prevent infection, and hasten skin repair.

	Tiffany also developed vaginal stenosis, an often overlooked adverse effect of pelvic radiation. “If not dealt with proactively, vaginal stenosis can significantly impair sexual function,” says Moffitt Cancer Center radiation oncology nurse Gloria Wood, RN, BSN. “It can make intercourse and even vaginal exams extremely painful or even impossible, adversely affecting quality of life.”

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

Articles

Patient Focus

For Tiffany Keller-Fritz, the safety of her unborn child, weighed against the urgent need to initiate treatment, required close collaboration between her oncologists and OB-GYN.

Squamous Cell Carcinoma of the Anus During Pregnancy

	Forty years after the declaration of war on cancer, one of the most profound shifts in cancer care today is a new focus on treating those living beyond cancer, as well as those living with cancer.

 We celebrate the news that there are more than 2.6 million people in the United States who have a history of breast cancer, yet are alive today.

 Oncology professionals, including nurse navigators, must address the specific needs of breast cancer survivors as their numbers continue to grow. In order for the oncology care community to sustain excellent outcomes for these survivors, there are several important questions to consider:

Will medical oncologists continue to provide long-term breast cancer follow-up care?

	A recent survey found that 91% of breast cancer patients expect their oncologists to direct their follow-up care. Over the past two years, the American College of Surgeons and the Institute of Medicine have released reports that predict a severe shortage of medical oncologists (MOs) and other oncology-related healthcare personnel over the next 10-20 years.

 The expected shortage and ongoing changes to insurance reimbursement models are two factors that may accelerate the transition of breast cancer follow-up care from oncology specialists to primary care providers (PCPs). It is imperative that PCPs receive the support and education they need in order to provide safe and effective care during this transition.

Are primary care physicians ready to treat breast cancer survivors?

	A nationwide study of barriers between PCPs and MOs revealed several clear themes. Cosponsored by the National Cancer Institute and the American Cancer Society, the Survey of Physician Attitudes Regarding the Care of Cancer Survivors was returned by 1072 PCPs and 1130 MOs providing care to breast and colon cancer survivors, a 57% response rate.

 PCPs were more likely than MOs to report ordering tests or treatments primarily as malpractice protection, being concerned about missing care, and lacking adequate training to manage patient problems. MOs were more likely than PCPs to report concerns about duplicated care. They also exhibited less confidence in PCPs’ skills to manage breast cancer than the PCPs did themselves. These results highlight the need for greater PCP support and training in breast cancer followup care, and the need for oncologists to promote and support that care by providing thorough treatment summaries and survivorship care plans.

How will breast cancer follow-up care be supported?

	National standards are being discussed but are far from being finalized, so it is vital that evidence-based information about breast cancer follow-up care best practices is available to all stakeholders. In the fall of 2011, medical oncologist Robert Fisher, MD, formed a nonprofit organization to accomplish this very goal, as expressed in its mission statement: “The Pink Ribbon Survivors Network exists with the dual purpose of serving the needs of breast cancer survivors and the needs of health care professionals that care for breast cancer survivors.”

 The website offers a comprehensive online library that provides information for three primary groups: PCPs, survivors, and oncology professionals, including oncology nurse navigators (ONNs). These groups are all represented on the board.

	In September 2011, the LIVESTRONG organization sponsored a meeting in Washington, DC, that brought together 150 community leaders, cancer experts, cancer survivors, and their advocates to identify the essential elements of survivorship care delivery. One of the five elements that received unanimous consensus was having a “strategy which addresses care coordination with primary care physicians and primary oncologists.”

 As plans evolve to provide support for breast cancer survivors throughout their lives, oncology nurse navigators must stay informed about the process and know how to access resources that will help make this goal a reality.

			MD Anderson Cancer Center. Stages of Cancer Survivorship. MD Anderson Cancer Center website. 

http://www.mdanderson.org/patient-and-cancerinformation/cancer-information/cancer-topics/survivorship/stages-ofcancer-survivorship/index.html

			American Cancer Society. What are the key statistics about breast cancer? ACR website. 

. Updated June 11, 2012. Accessed Aug. 8, 2012.

			Debono D. Coping With the Oncology Workforce Shortage: Transitioning Oncology Follow-Up Care to Primary Care Providers.

			Potosky AL, Han PKJ, Rowland J, et al. Differences Between Primary Care Physicians’ and Oncologists’ Knowledge, Attitudes and Practices Regarding the Care of Cancer Survivors. 

			Pink Ribbon Survivors Network. Our Mission. Pink Ribbon Survivors Network website. 

			Rechis R, Beckjord EB, Arvey SR, et al. The Essential Elements of Survivorship Care: A Livestrong Brief. Livestrong website. 

https://livestrong.org/pdfs/3-0/EssentialElementsBrief

. Published December 2011. Accessed January 3, 2011.

Nurse Navigators

Forty years after the declaration of war on cancer, one of the most profound shifts in cancer care today is a new focus on treating those living beyond cancer, as well as those living with cancer.

Navigating Breast Cancer Survivorship: Sustaining the Good News

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

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

		Louisiana State Health Sciences Center in New Orleans, Louisiana

	The American Society of Clinical Oncology (ASCO) is often thought of as an organization for physicians who provide cancer care. However, ASCO offers a host of resources for other cancer care providers and patients with cancer.

	For instance, the ASCO Annual Meeting is recognized as a top-notch educational and scientific event, and because it’s not possible for everyone to attend, ASCO is offering its June 2012 Virtual Meeting for purchase via its ASCO University Bookstore (

). The Virtual Meeting includes podcasts and iMeeting, a mobile app that enables purchasers to access sessions on their computers, Apple devices (iPhone, iPad, iPodTouch), Android, or MP3/MP4-compatible devices. For meeting attendees, access to the Virtual Meeting is included with paid registration.

) also has resources and information for cancer care providers. The ASCO Abstract Database is a repository for meeting abstracts, and the entire collection can be searched at no charge at 

. There is a “browse abstracts by meeting” drop-down menu with links to multiple ASCO meetings (eg, annual meeting, breast cancer symposium, molecular markers meeting) held from 2007 on. Another section of the site that many clinicians find helpful is the Practice & Guidelines section, available at 

. Here you’ll find clinical practice guidelines, tools and resources, and clinical evidence reviews. The site has useful information on a variety of topics, including survivorship, fertility preservation, and specific treatment-related issues such as appropriate chemotherapy dosing for obese patients. Clinicians also can access summary slide sets on topics such as palliative care, antiemetics, growth factors, and prevention of venous thromboembolism. ASCO’s website is truly a treasure trove of current, evidence-based information.

) provides news for patients and their families and friends about cancer care and treatment advances announced during the annual meeting. The site also posts scientific news when it becomes publicly available. Patients and their families can sign up to receive the newsletter Inside Cancer.Net. Cancer.Net also can be followed on Facebook or Twitter, where real-time updates are posted. The website helps people with cancer to put complex scientific information into context via its research summaries, audio podcasts, patient education videos, patient advocacy programs, and Annual Meeting Highlights of the Day. Cancer. Net also is home to information on clinical trials, side effect management, coping, survivorship, 120 types of cancer and cancer syndromes, and more. Content is written in simple, easy-to-digest language and verified by the Cancer.Net Editorial Board. It is also available in Spanish.

	ASCO notes that well-informed patients are their own best advocates and invaluable partners to their cancer care providers. Patient advocates may attend the ASCO Annual Meeting at a discounted registration rate and are offered a wide range of opportunities in connection with the event, including a pre-meeting webinar on research highlights that occurs at the same time the ASCO news embargo lifts, so participants receive timely access to this information and are able to ask questions of ASCO experts. At the annual meeting, ASCO provides a lounge where patient advocates can gather in a relaxed environment to take a break, use computers, and network. Patient advocates can also set up exhibit booths during the meeting, a great opportunity for them and for providers who stop by to view the displays.

	ASCO notes that well-informed patients are their own best advocates and invaluable partners to their cancer care providers.

	Next year’s ASCO Annual Meeting will be held at McCormick Place in Chicago May 31-June 4, 2013. If you’re not able to attend in person, remember that you’ll be able to attend virtually. And in the meantime, check out the valuable resources available on ASCO’s website at 

Nurse's Notes

The American Society of Clinical Oncology offers a host of resources for cancer care providers and patients with cancer.

August 2012

Squamous Cell Carcinoma of the Anus During Pregnancy

Navigating Breast Cancer Survivorship: Sustaining the Good News

ASCO Offers Resources for You and Your Patients