			Denise Soltow Hershey, PhD, RN, FNP-BC

		Assistant Professor, Michigan State University College of Nursing

	It is estimated that 8%-18% of all cancer patients will have preexisting diabetes at the time they are diagnosed with cancer.

 Individuals with cancer and diabetes have higher mortality rates and a higher risk for developing infections and/or being hospitalized while receiving treatment when compared with individuals with cancer who do not have diabetes.

 The level of glycemic control during treatment has been hypothesized as one of the reasons for this difference.

	Many factors can impact glycemic control in individuals with cancer and diabetes. These include chemotherapeutic agents; medications, such as corticosteroids; the impact symptoms may have on self-management of diet and exercise regimens; and lack of communication or coordination of care between oncologists and the patient’s primary care/diabetes providers. Patients also may perceive their cancer as being more severe, therefore prioritizing their cancer treatment over managing their diabetes.

	Patients with cancer and diabetes require a patient-centered approach to the management of both diseases while they are undergoing cancer treatment. The American Diabetes Association released new guidelines in 2012 for a patient-centered approach for the management of hyperglycemia in Type 2 diabetes,

 and these guidelines are available at www.diabetes.org. This patient-centered approach allows for individualization of glycemic goals based on the individual’s health status, complications, and resources, taking into account:

			Impact of fatigue and depression on ability to exercise

			Effect of chemotherapy and other medications on glycemic levels

			The influence of loss of appetite, nausea, or vomiting on diet

			How medications (eg, corticosteroids) and the disease process may affect nutritional state and tumor-induced alterations in metabolism

			Feelings of being overwhelmed with the challenges of managing both cancer and diabetes, including multiple appointments with various healthcare providers

	To assist patients in the management of their diabetes, the American Association of Diabetes Educators has identified seven essential selfcare behaviors (

 Oncology nurses should incorporate the assessment of each of these areas into their routine evaluations when they encounter a patient with diabetes and cancer, and provide education regarding the potential impact cancer and its treatment may have on glycemic levels.

			Box. Self-Care Behavior for Patients with Diabetes

			2.Healthy eating; for cancer patients, this would include assisting them in developing a practical meal plan which includes eating regular meals that include carbohydrates, proteins, and fats.

			3. Monitoring of blood glucose levels; how often patients check may need to be increased while they are receiving treatment for their cancer.

			5. Problem-solving, eg, how to watch for and handle hyper- and hypoglycemic levels as well as interruptions to their usual routine

			6. Reducing risks for infections and other complications

For more information and handsouts, visit www.diabeteseducator.org.

	Oncology nurses may need to take on the role of care coordinator to assist patients in managing the care they receive from their oncologists and primary care providers and empower patients to communicate with their providers regarding their current level of glycemic control. The oncology nurse also may need to advocate for referrals to diabetes educators or an endocrinologist to assist patients in maintaining optimal glycemic control while they are receiving treatment.

	The most important thing oncology nurses can do is to incorporate the use of evidence-based guidelines for diabetes management into their routine. These guidelines will assist the oncology nurse in providing the individualized care patients with diabetes and cancer will need in order to achieve optimal outcomes, reduce complications, and improve overall health-related quality of life.

				Barone BB, Yeh HC, Snyder CF, et al. Postoperative mortality in cancer patients with preexisting diabetes: systematic review and meta-analysis. 

				Giovanucci E, Harlan D, Archer M, et al. Diabetes and cancer: a consensus report. 

				Barone BB, Yeh HC, Snyder CF, et al. Long-term all-cause mortality in cancer patients with preexisting diabetes mellitus: a systematic review and meta-analysis. 

				Hershey DS, Tipton J, Given B, Davis E. Perceived impact of cancer treatment on diabetes self-management. 

				Leak A, Davis E, Houchin L, Mabrey M. Diabetes management and self-care education for hospitalized patients with cancer. 

				Psarakis H. Clinical challenges in caring for patients with diabetes and cancer. 

				Inzucchi S, Bergenstal R, Buse J, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). 

				American Association of Diabetes Educators. AADE 7™ Self-Care Behaviors. http://www.diabeteseducator.org/. Accessed June 26, 2013.

Articles

Partner Perspectives

It is estimated that 8%-18% of all cancer patients will have preexisting diabetes at the time they are diagnosed with cancer.

Improving Glycemic Control in Individuals With Cancer and Diabetes

	Oncology nurses have a great opportunity to prevent cancer—not just treat it! Media outlets recently reported Michael Douglas’ diagnosis of throat cancer and his statement that human papillomavirus virus (HPV) infection caused his cancer. Oncology nurses can lead the way in efforts to protect the next generation from this type of cancer if they know the facts about HPV vaccination for both girls and boys.

	HPV is the most commonly acquired sexually transmitted infection (STI) in the United States for individuals aged 16 to 24, according to the Centers for Disease Control and Prevention (CDC). It is so common that at least 50% of sexually active men and women acquire this infection at some point in their lives. Unlike many other STIs, HPV can be spread through skin-to-skin contact during sexual play as well as through all types of intercourse.

	Most people with HPV do not develop symptoms or health problems, so they may not even know they have the infection. In 90% of cases, the body’s immune system clears HPV naturally within 2 years. However, four of the 40 HPV strains have been linked with cervical cancer. Chronic HPV infection of one specific subtype (DNA subtype 16) has been associated with cervical cancer and cancers of the mouth, throat, head, and neck.

	HPV-related cancers can be prevented through HPV vaccination, which is approved for both men and women. The effectiveness of the HPV vaccination for females has recently been shown to be better than expected.

 However, HPV infection is not just a concern for women. HPV currently is estimated to infect young men 20 years of age and older at rates between 65% and 93% in highrisk populations and up to 45% among lower-risk populations.

	Unfortunately, the benefit of the HPV vaccine in boys is often overlooked by the initial focus and marketing of the HPV vaccine as a means to prevent cervical cancer. Vaccinating boys and men aged 9-26 years can prevent more than 40,000 cancer-related deaths over the next century, while saving $25,700 per quality-adjusted life-year.

 Unfortunately, despite the usefulness of the vaccine in preventing HPV-related cancers in men, barriers to HPV vaccination still persist.

	To increase vaccination rates for boys, nurses can use family-centered strategies to increase parents’ knowledge of HPV vaccination,

 including awareness of the new HPV immunization guidelines from the Advisory Committee on Immunization Practice (ACIP) at the CDC. These guidelines recommend three doses over 6 months, with the second dose given 1-2 months after the first, and the third dose given 6 months after the first dose for boys and girls aged 11 or 12 years old.

 It is also critical to establish parental awareness of the pathology associated with HPV, including the increasing rates of mouth, head, and neck cancers secondary to HPV infection.

	In order to increase vaccination of adolescent males, all adults—and especially men, fathers, and father figures&mdash;must understand that HPV infection and related HPV cancers are not just “women’s diseases.” The HPV vaccine is just as important for the future health of a boy as it is for a girl. In addition, studies show that HPV vaccination does not promote sexual promiscuity as many people have thought or feared&mdash;an important point to include in patient education.

	The Nell Hodgson Woodruff School of Nursing at Emory University is studying how to break down barriers to vaccination, especially in hardto- reach populations such as families living in rural areas. Assistant professor Tami Thomas has been conducting cancer prevention research in rural communities with a focus on a communitybased, participatory approach. Since 2008, she has engaged parents, pastors, teachers, and community leaders to understand why parents choose to vaccinate their children with the HPV vaccine. Her next step includes development of a culturally specific intervention to increase vaccination rates.

	Oncology nurses will no longer just be treating HPV-related cancers, but instead working to prevent cancer. All nurses have a role in informing parents that HPV vaccination can prevent cancers for both girls and boys.

				Markowitz LE, Hariri S, Lin C, et al. Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, National Health and Nutrition Examination Surveys, 2003-2010. 

				Schiller JT, Day PM, Kines RC. Current understanding of the mechanism of HPV infection. 

				Thomas TL, Snell S. Vaccinate boys with the HPV vaccine? Really? 

				Centers for Disease Control and Prevention. Recommendations on the use of quadrivalent human papillomavirus vaccine in males—Advisory Committee on Immunization Practices (ACIP). 

				Thomas TL, Strickland OL, DiClemente R, Higgins M, Haber M. Rural African American parents’ knowledge and decisions about human papillomavirus vaccination. 

Oncology nurses can lead the way in efforts to protect the next generation from this type of cancer if they know the facts about HPV vaccination for both girls and boys

Promoting HPV Vaccination for Girls and Boys

		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

A hot topic of discussion at the American Society of Clinical Oncology (ASCO) meeting in June was the Patient Protection and Affordable Care Act (often referred to as the ACA) and what it means for the future of oncology care in the United States. As oncology providers, we are well aware of the drivers for this legislation. Lack of access to medical care, lack of health insurance coverage, rising costs, and an outdated reimbursement system (provider payments based on volume), have all led to a crisis in healthcare. The ACA was enacted to address these issues by improving access to healthcare, improving and rewarding quality care, and decreasing costs.

On March 21, 2010, the ACA was signed into law by President Obama, and on June 28, 2012, the US Supreme Court validated the constitutionality of the legislation. Provisions of the ACA allow young adults to continue healthcare coverage on their parents’ insurance plans until the age of 26, prohibit the denial of coverage to individuals with preexisting conditions (which is very relevant to our patient population), provide incentives for the expansion of Medicaid, and implement significant changes to the delivery system to increase healthcare innovation.

The ACA will expand healthcare coverage to an additional 25 million Americans according to recent estimates by the Congressional Budget Office. Much of this expansion is through the Medicaid program, which will cover childless adults and establish health insurance exchanges that will offer an insurance option for individuals and families who are either unemployed or are not offered insurance through their employer.

All new or renewing private healthcare insurance plans are now required under the ACA to cover the costs of 45 preventive services that were identified by the US Preventive Services Task Force as essential for reducing future medical burden. Covered services relevant to oncology care include colonoscopy screening, Pap testing, and mammograms. The ACA also eliminates any copays, deductibles, and other cost sharing for preventive services. Medicare Part D’s “donut hole”—the gap in coverage that occurs when a beneficiary exceeds the drug coverage limit&mdash;is often a concern for people being treated for cancer. Once patients reach the drug coverage limit, they are expected to pay for all of their drug costs until they reach a catastrophic protection level and their drug coverage will resume. The ACA aims to close the gap by providing discounts for generic drugs, subsidizing name-brand drugs, and raising the initial coverage limit to meet the coverage-gap threshold.

The ACA also identifies Essential Health Benefits services that Medicaid and other insurance plans that wish to participate in the healthcare insurance exchanges must cover by 2014: ambulatory services; emergency services; hospitalization; maternity, newborn, and pediatric care; mental health services; prescription drugs; rehabilitative services; and laboratory services. Another benefit of the ACA is that insurance companies will no longer be allowed to deny coverage of routine medical costs for patients participating in a clinical trial.

Also being phased out under the ACA are spending caps that health plans have traditionally set for services that are considered Essential Health Benefits. Before this provision, health plans were able to set an annual or lifetime limit on what they would spend on a beneficiary’s covered benefits, and once this amount was exceeded, patients had to bear further costs of care.

The ACA supports the Physician Quality Reporting System (PQRS) program to leverage incentive payments and payment adjustments for eligible physicians who contribute quality information, and makes the data available to the public. Starting in 2015, the program has the authority to impose a payment penalty if a physician does not adequately meet the reporting requirements or quality standards.

In an effort to reward delivery of high-quality care over high volume of care, the ACA also introduced the bundled payment initiative, which provides reimbursement based on the episode of care and encourages care coordination. Additional cost-savings measures, such as accountable care organizations and medical homes, also are being explored, and oncology nurses will likely be on the forefront of these initiatives.

Nurse's Notes

A hot topic of discussion at the American Society of Clinical Oncology (ASCO) meeting in June was the Patient Protection and Affordable Care Act (often referred to as the ACA) and what it means for the future of oncology care in the United States.

The Affordable Care Act: What Nurses Need to Know

			Michigan State University College of Nursing

			Florence Schorske Wald Professor of Nursing

			Clinical Faculty, Frances Payne Bolton School of Nursing at Case Western Reserve University

			Clinical Nurse Specialist University Hospitals Seidman Cancer Center

			Director of Nursing Research at The James Cancer Hospital & Solove Research Institute Clinical Associate Professor The Ohio State University College of Nursing

This is the first part of a three-part series spotlighting key issues and challenges for oncology nurses practicing today. Oncology Nursing News was honored to host a roundtable with faculty leaders from some of the top schools and colleges of nursing with oncology programs— many of which are members of our Strategic Alliance Partnership initiative&mdash;who were in Washington, DC, for the 2013 Annual Congress of the Oncology Nursing Society. Here, we feature panelists’ perspectives on the critical role played by oncology nursing professionals in helping patients with cancer to manage their symptoms and any treatment-related adverse events. For video highlights from our Oncology Nursing News roundtable, 

 The value of nursing in symptom management is so important and becoming increasingly so, as the treatment becomes more complex. While our healthcare system struggles with how care is going be coordinated, nursing remains key, not only to the success of patients, but also to the success of family caregivers in helping these patients. Nurses work across the care continuum and across healthcare settings in a role that is continually evolving. There are approximately 200 pipeline drugs in oncology,and many are oral agents with new side effects. As more responsibility falls upon the patient to manage these oral therapies at home, nurses must gain new knowledge to assist them and also engage family care.

What does the future now hold for nurses in this complex care environment? What are the information needs, and how does this information get communicated to nurses and patients?

 We have 12 disease-specific clinics at our institution, for breast, lung, etc. where nurses can amass a body of knowledge that is evidence-based, but nurses in community practices often see patients across many tumor types. They have to know everything. How do you wrap your mind around that? How can we give them enough information, whether it is through our nursing education programs or after graduation? How do we keep them current on these issues that patients experience? Symptom management and monitoring by nurses is critical. They are really the patient’s lifeline, so we need to set up a system for communicating with patients. The best way to do that is to be able to see the same patient. Some practices understand the benefits of the nurse seeing the same patient and building that relationship of trust, because you want patients to call back if they are having a problem. If you are dealing with someone who is receiving radiation and chemotherapy, it’s a double whammy. As nurse educators, we have the responsibility to set up systems and provide tools that will help nurses meet these challenges and make their jobs easier.

 There is a thirst for continuing education. Once you graduate—and especially when working in an oncology facility or specialty&mdash; you are going to have to stay up to date and seek out continuing education or certifications. It also is really important to teach nurses how to work with interdisciplinary teams. We can’t do it all. We may be the coordinator, or we may be the person who the family trusts. But we also have to work with physical therapists, speech and language therapists, and other disciplines involved in the patient’s care&mdash;communicating, coordinating, and continuing to improve care.

 Nurses need to gain a lot of technical expertise, whether it is cardiac monitoring on the oncology unit or managing complex patients who used to be monitored in the ICU. Much of the nurse’s role revolves around the whole area of symptom management and care coordination. This is where nurses often can have the biggest impact for the patient and the family, and it is really a very rewarding part of many staff nurses’ practice—to work with patients and families very closely, identify problems, and make the appropriate referrals to other team members.

 Nurses are very good at symptom management. We have done so much research in pain management since the 1980s, and also in managing nausea and fatigue. Now, as many of the therapies are going to be oral agents to be administered at home by family members, education becomes increasingly important. When these issues come to nursing, we are there, ready to address them. This is an arena where we shine.

 Yes, there has been a huge body of research done by nurses, and that can make a difference. How do you disseminate those research results?

 Dissemination has always been an issue. I’m proud of how far we’ve come, but that is the work we have to do, to improve on our dissemination mechanisms, to think about how we collect data and get it to the folks who need it.

We’ve looked at this from the nurse’s perspective. What are the symptom management challenges for patients? What should they be looking to oncology nurses for?

 Our goal—especially with patients who are early-stage and have a good prognosis&mdash;is for them to become their own self-managers. There are periods of time when patients are vulnerable and unable to care for themselves, so nurses can teach the caregiver during those times. Empowering is critical: empowering the patient and the caregiver to know what to expect, to be able to take their medicines on time, to be able to recognize when something might happen and get early intervention to prevent a complication. The 

  is now used in many places across the country, and for patients to have this resource at home is really useful. They can see that they are experiencing symptoms that many other patients have and understand that this is part of what they should expect to be experiencing.

 In pediatric cases, one of the things I like to do is have the patient guide the visit, asking them, “What are your questions? What do we need to address today?” It is important to educate patients that this is their visit. Also unique to pediatrics is that children are constantly developing, so we must add that component in as well. There are a lot more variables that we have to take into account.

 So much of this comes to families now. Patients are discharged earlier and may be a little more compromised than in the past. And, as other family members themselves face the comorbidities that often come with aging, this can affect the effectiveness of caregiving, for example, remembering all of the medications. This is a growing problem. Families do a great job, but they need our support with these often very complicated treatment regimens. Nurses are trained to do this, and we do it well. I also would hope to see more resources directed to home care.

What should nurses be looking to in the future? How will changes in the healthcare system affect practice, and what would you like to see nurses more involved in from a symptom management perspective?

 With Obamacare, nurses have an opportunity to step up. There are people who champion the role of the nurse practitioner, and clearly, there are not going to be enough physicians in some areas of the country. If nurses can do it—which they can&mdash;and take advantage of this opportunity, it will be amazing.

 I would love to see nurses establish palliative care clinics, with advanced practice nurses having their own clinics, with their own schedules, and managing patients. I think cancer centers who really understand the needs of patients will begin to think about doing that.

 We also need to think about how we are going to integrate technology into support for patients and families in symptom management. There are many apps out now for recording all kinds of information, and the professional organizations are also producing these apps. How these are integrated, so that families can use them, is really important. And we have to consider those patients who aren’t appsavvy as far as symptom management goes. This is an important area of research for the future.

The value of nursing in symptom management is so important and becoming increasingly so, as the treatment becomes more complex.

August 2013

Improving Glycemic Control in Individuals With Cancer and Diabetes

Promoting HPV Vaccination for Girls and Boys

The Affordable Care Act: What Nurses Need to Know

Symptom Management: An Expanded Role for Nurses in Educating and Supporting Patients