	Otolaryngology Clinical Nurse Specialist

	The Ohio State University Medical Center, Columbus

	Adjuvant chemotherapy is now the standard of care for early resectable NSCLC, with cisplatin/vinorelbine (CVb) being the most common doublet used. As Belani points out, this treatment is not without difficulty. Toxicities identified in the initial study included neutropenia (88%), fatigue (81%), nausea (80%), anorexia (55%), vomiting (48%), neuropathy (48%), and constipation (47%), with severe (> grade 3) toxicities occurring 40% of the time (

	This is why the TREAT study looked at a different combination of agents comparing CVb to cisplatin/pemetrexed (CPx). As discussed, the outcomes of this adjuvant therapy were comparable to CVb with less toxicity, and thus fewer treatment reductions or delays.

	Continued use of these and other chemotherapy regimens as maintenance therapy has switched the idea of NSCLC as a chronic disease rather than an acute disease. Nurses may be in the prime role for this paradigm switch. Not only is the nurse the first person to assess the patient and his/her toxicities, but they are crucial to educating the patient about potential problems to report. Knowing the degree of toxicity and early recognition may help to decrease the amount of delay in treatment.

	The next step that Belani discussed is delving deeper into the knowledge that there are specific mutations in NSCLC that respond differently to different treatments. Patients with NSCLC with 

 mutations have been successfully treated. The IPASS study looked at gefitinib versus conventional chemotherapy, with gefitinib demonstrating longer progression-free survival and increased response rates. Erlotinib was subsequently studied with equally good results. However, patients with specific 

 gene mutations develop erlotinib resistance after time.

Changing Paradigms for NSCLC in Personalized Therapy Era

	PARP inhibitors originally instilled a great deal of optimism in helping treat women with breast cancer. While the initial hope and promise for PARP inhibitors has declined significantly, there is still belief in its use in triple-negative disease, especially with a DNA mutation of 

	Since triple-negative breast cancer is more aggressive and requires more aggressive neoadjuvant intervention, the PARP inhibitors continue to show possibility. Clinical trials that continue to explore the potential benefits along with a combination of therapy are encouraging. PARP inhibitors as a monotherapy do not seem to show a significant improvement in pretreated triple-negative disease. It is, however, imperative that clinical trials continue looking more closely at various biomarkers and combination therapy.

	It is too soon to abandon hope in PARP inhibitors altogether. Perhaps it is more important to look at a combination of therapies, timing, dosing and the long-term survival advantage when other interventions have not been successful.

PARP Inhibition Explored in Triple-Negative Breast Cancer

	Laura Metcalfe, MSN, RN, APN, C, AOCNS®

	John Theurer Cancer Center, Hackensack, New Jersey

	Cancer fatalism beliefs have been shown repeatedly to thwart screening and treatment, according to Barbara Powe, PhD, director of underserved population research at the American Cancer Society (J Natl Cancer Inst. 2007;99[16]:1222-1223). I think it is incumbent upon nurses, especially oncology nurses, to educate the public about the importance of screening. Screening can detect cancer at an earlier stage and, as we know, earlier detection leads to better outcomes and even cures. I would be remiss if I didn’t also point out that screening colonoscopies cannot only detect cancer at an early stage, but can sometimes stop cancer from developing (by removing precancerous polyps).

	Of course, even better than early detection through screening is outright prevention. By exercising, eating a healthy diet, and not smoking, many cancers can be avoided. However, studies have shown that those people who have a fatalistic attitude toward cancer also believe there’s nothing they can do to prevent it. It would seem logical that this would be the place to start in educating the public. Getting people to understand the connection between an unhealthy lifestyle and the increased risk for cancer would, hopefully, lead to changes in behavior.

	In recent years we’ve learned that exercise and a healthy diet (eg, fruits, vegetables, whole grains, fish) are linked to decreased heart disease, arthritis, Alzheimers, depression, and even cancer. While change is often slow, my hope is that we will see the effects of all this information related to diet over the next few years with decreased obesity and its all-too-familiar comorbidities. I think it naturally follows that if people adopt a healthier lifestyle that they will begin to feel more control over their health. A sense of control has been shown in other diseases (eg, diabetes, heart disease) to impact health behaviors.

	If people understood, and believed, that a healthy diet and lifestyle could help them decrease their risk of certain cancers, it should follow that they would be more likely to undergo the appropriate cancer screenings. In summary, while an individual’s beliefs are often deeply ingrained and difficult to change, nurses need to continue to educate people in order to effect change. As pointed out in this study, screenings were low even when healthcare was free. While access to care is still of paramount importance, changing beliefs, especially fatalism towards healthcare, is even more important to ensure that people actually undergo the appropriate cancer screenings.

Lower Rate of Colorectal Cancer Screening May Be Linked to Higher Cancer Fatalism

	Radiation Oncology Nurse/Patient Navigator

	The first part of the ongoing RTOG 0617 trial asks, “Does high-dose radiation therapy (74 Gy) offer an overall survival benefit to patients with stage III NSCLC compared with standard care (60 Gy)?” One can only agree that the advantages of low-dose radiation (60 Gy) outweigh those of the high-dose (74 Gy) and should be the standard going forward. Especially since the Data Safety Monitoring Board (DSMB) stepped in and closed the 2 high-dose arms due to the futility threshold being crossed. Not to say that high-dose is specifically detrimental by itself, but the combination with chemotherapy and cetuximab might be the culprit. Once the data are released, we will know if there was a significant negative impact on patients with the use of the high-dose radiation, or if it was just not improving nor hurting patient outcomes.

	From a nurse’s perspective this is an excellent chance to educate the patient in the quality-of-life components of this study. This is an opportunity for patients to report main toxicities during chemoradiation. Prior studies have reported how significant sensitive and meaningful methods are to accurately capture normal tissue toxicities from patient report outcomes (PROs) are. Since one of the multivariate analyses for worse survival was radiation dose with toxicities, this is important.

	The second part of the trial asks, “Is there a survival benefit with cetuximab?” The 2 arms randomizing patients to 60 Gy with concurrent chemotherapy with or without cetuximab remain open to accrual. Although cetuximab in this trial remains experimental and not approved by the FDA for treatment of lung cancer, it is encouraging as shown by previous phase I, II, and III clinical trials involving NSCLC.

No Survival Advantage for High-Dose Radiation Versus Standard-Dose Radiation in Stage III NSCLC

Articles

Feature Story

Nurses provide their unique perspectives on many of the recent clinical trials and developments in cancer research.

Oncology Nurse Perspectives on Developments in Cancer Care

		Robert Morreale/Visual explanations, LLC

	Older patients with advanced hematologic malignancies who receive a minimally toxic nonmyeloablative regimen before allogeneic hematopoietic cell transplantation (HCT) have favorable overall survival (OS) and progression-free survival (PFS) rates, according to the results of a recent study.

	Mohammed L. Sorror, MD, with Fred Hutchinson Cancer Research Center, and colleagues examined outcomes in 372 patients who underwent conditioning with a low dose of total body irradiation either alone or combined with 90 mg/m2 of fludarabine prior to HCT. Postgrafting immunosuppression included mycophenolate mofetil plus a calcineurin inhibitor (cyclosporine or tacrolimus) in different schedules.

	Subjects were aged 60 to 75 years with advanced hematologic malignancies who underwent HCT in multicenter prospective clinical trials from 1998 to 2008. The patients were divided into 3 groups according to age: 218 patients were aged 60 to 64 years, 121 patients were aged 65 to 69 years, and 33 patients were aged 70 to 75 years.

		Adult Blood & Marrow Stem Cell Transplantation Program

		While the prevalence of most hematologic malignancies increases with age, advanced age has historically been a limiting factor to proceed with HCT. With the advent of nonmyeloablative conditioning regimens, patients who may have been previously excluded from HCT due to older age may now be eligible for transplant.

		Sorror et al, report a 5-year survival rate of 35% with minimal organ toxicity. These results are encouraging, and may offer a potentially curable treatment to older adults who are ineligible for myeloablative conditioning regimens.

		Older patients undergoing allogeneic HCT have different issues compared to younger patients. These include the number of comorbidities and its effects in terms of medication interactions; prescription coverage, as many of these patients have Medicare; and increased organ toxicity.

		Utilization of a nonmyeloablative conditioning regimen addresses each of these issues, making it reasonable to consider HCT in patients otherwise ineligible. Evaluating patients and utilizing risk assessment strategies to determine functional age (compared to chronological age) may help predict which type of conditioning regimen is best suited for each individual.

		The projected incidence of newly diagnosed hematologic malignancies is climbing; therefore, incorporating curative treatment options to a larger subset of this population is undoubtedly appealing. By broadening the eligibility criteria for HCT, future direction and possible changes made to healthcare policy may be necessary.

	Irrespective of age, the 5-year OS and PFS rates were 35% (95% CI, 30%-40%) and 32% (95% CI, 27%-37%), respectively. The 5-year survival rates ranged from 23% (95% CI, 11%-35%) in patients who had high comorbidity burden, and high relapse risk to 69% (95% CI, 44%-95%) in patients with low comorbidity burden and low relapse risk. Also, half of these patients were never hospitalized, and two-thirds of survivors had eventual resolution of their chronic graft versus host disease with restoration of normal or near-normal physical function as demonstrated by their Karnofsky Performance Status scores.

	Sorror and associates said that their findings are “encouraging,” especially with respect to relapse, considering the poor outcomes seen with nontransplantation treatments. They did note, however, that a major drawback of their study was the lack of a control group receiving standard therapy or supportive care.

	Increasing age has long been blamed for the higher mortality after high-dose allogeneic HCT for patients with hematologic malignancies. The intense, cytotoxic conditioning regimens that precede transplantation are intended to decrease tumor burden but may cause organ toxicity. As a result, only younger, healthy patients have been deemed eligible for high-dose HCT.

	A longstanding cutoff age of 55 to 60 years has meant that most patients with hematologic malignancies have been denied allogeneic HCT, given that hematologic malignancies are primarily diseases of the elderly, with the median age at diagnosis of most hematologic malignancies ranging from 65 to 70 years.

	Also, the availability of good treatment options for older patients with advanced hematologic malignancies is becoming increasingly important. With current demographic trends, it is projected that 20% of the population will be aged 65 years or older within the next 2 decades, and also that the number of newly diagnosed hematologic malignancies in older populations will increase by 77%.

	Sorror ML, Sandmaier BM, Storer BE, et al. Long-term outcomes among older patients following nonmyeloablative conditioning and allogeneic hematopoietic cell transplantation for advanced hematologic malignancies. 

Older patients with advanced hematologic malignancies who receive a minimally toxic nonmyeloablative regimen before allogeneic HCT have favorable OS and PFS rates.

Nonmyeloablative Conditioning Before Cell Transplantation Shows Potential in Older Patients With Hematologic Malignancies

Executive Director, President, and Co-founder

National Coalition of Oncology Nurse Navigators

	2011 was a banner year for the National Coalition of Oncology Nurse Navigators (NCONN), as our membership has continued to grow and we held our 3rd Annual 

Conference. Additionally, with our partnership with 

 we have been able to provide oncology nurses and nurse navigators with insight and resources through our 

 columns and coverage of our annual conference. Here’s a look back at some of the areas we covered this past year.

	From the time of engagement, the navigator is “hand in hand” with the patient, identifying obstacles and barriers that may derail a successful completion of treatment and transition to survivorship. This is the navigator’s role and area of expertise.

	Survivorship care plans—individualized survivorship blueprints&mdash;are increasingly being used in oncology care. Navigators can be instrumental in educating patients and helping them to develop these plans. Discussions of survivorship care plans should start as soon as a patient is diagnosed with cancer. 

	Oncology nurses expend a tremendous amount of energy and concern as they care for patients who may or may not recover from their illness. Compassion fatigue may not happen with the care of 1 patient, but the repeated exposure to oncology patients may lead to the condition.

	For the oncology nurse, combating compassion fatigue starts with recognizing the symptoms and making changes that lead to a personal transformation. Develop a personal statement to guide your life, self, and family. Also ask yourself, “Why am I in this profession? What is my mission?”

	Nurses with compassion fatigue need to recharge their batteries daily, by committing to such things as exercise and eating healthier. They should also make it a priority to engage with what they value most, which often means connecting with family and friends. 

	Consistent with national trends, NCONN is developing a healthcare oncology nurse navigator (ONN) model that provides education and support for the professional nurse navigator.

	Apart from the roles of a licensed nurse, the ONN needs to develop competencies to integrate the roles of healthcare promoter, educator, counselor, care coordinator, case manager, researcher, and patient advocate. Hence, education programs for preparing ONNs must ensure that professional nurse navigators are equipped with the essential competencies that enable them to fulfill these roles competently and ethically. Contact NCONN (

) to receive a copy of the ONN Core Competencies. 

	NCONN’s 3rd Annual Conference took place from September 8-10 in San Diego, California. ONNs from across the country gathered in the “Golden State” to network, mentor each other, and attend clinical sessions.

	Some of the highlights from the conference covered in the pages of 

 include a discussion with Harold P. Freeman, MD, FACS, on the current and future status of patient navigation, as well as clinical insights in breast cancer, brain cancer, oncofertility, and psychosocial considerations in cancer care.

	Cancer in adolescents and young adults (AYAs) is often detected late, and once diagnosed, these patients frequently receive inconsistent treatment and follow-up care.

	The needs of young adults with cancer have been overlooked historically, leaving these patients feeling neglected and ignored.

	ONNs navigating AYAs require an additional library of resources and a comprehensive understanding of AYA needs. Insurance issues, isolation, and quality-of-life concerns are the top-3 factors to consider when navigating an AYA patient. In all of these areas, assessment comes first and is crucial to successful navigation. 

	In 2012, as navigation continues to grow as a necessary component of oncology care, NCONN will continue to offer navigators the resources they need.

	Keep checking on nconn.org for details on our 4th Annual 

 Conference. Also, if there are issues related to oncology nurse navigation that you would like to see covered in 

Nurse Navigators

2011 was a banner year for the NCONN, as the membership has continued to grow and it held the 3rd Annual Changing the Face of Cancer Care Conference.

2011 in Review: NCONN Continues to Change the Face of Cancer Care

	There is an ongoing debate in the oncology community about a treatment technique that involves cutting all visible cancer out of the abdomen and then flooding the cavity with heated chemotherapy drugs. The procedure -- known as cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC), or a "hot chemotherapy bath" -- is used to treat peritoneal metastases resulting from several primary cancers, including colon cancer. Some oncologists and patients credit CRS followed by HIPEC with saving lives. Other oncology practitioners believe that more evidence -- in the form of a large, randomized, controlled study -- is needed before the double technique should be accepted as a standard of care for peritoneal carcinomatosis.

	According to David P. Ryan, MD, clinical director of the Massachusetts General Hospital Cancer Center, such a study would end debate about whether the techniques increase survival or simply appear promising because doctors tend to use them on their youngest, strongest patients -- those with less advanced cancer who might fare just as well if treated with systemic chemotherapy.

	"The [first] question is: Is there really long-term survival from this surgery? The second question is: Is it the cytoreductive surgery making a difference -- if there is one -- or [is it] a combination of cytoreductive surgery plus the HIPEC?" Ryan said.

	Based on the results he's documented within his practice, Paul Sugarbaker, MD, a pioneer of the techniques and director of the Peritoneal Surface Malignancy Program at the Washington (DC) Cancer Institute at Washington Hospital Center, who's been performing the procedures since the early 1980s, feels confident he can answer those questions. While it is true that he prefers to use the techniques on patients with less advanced disease, because the measures do not lead to long-term survival if any cancer is left behind, CRS plus HIPEC are that population's best hope for a cure, according to Sugarbaker.

	"If you can find for me, in the medical-surgical oncology literature, a patient who survived long-term with [only] systemic chemotherapy for peritoneal metastases, I'd like to know, but it's not out there," Sugarbaker said. "I can show you 30% of a whole group of colon cancer patients we've treated who are alive and well after 10 years."

	Even for believers, the procedures can be difficult. For doctors, performing the surgeries and unusual chemo delivery can mean remaining on their feet for up to 13 hours. And the aggressive operation can be a harsh experience for patients, who, according to Sugarbaker, spend 2 to 4 weeks recovering in the hospital and up to 6 months unable to work.

	In Sugarbaker's operating room, the surgery begins with the removal of the zyphoid bone and "the biggest abdominal incision you can make without going into the chest." Sugarbaker then removes large portions of the lining of abdomen and pelvis, in addition to any affected organs, wherever there's a malignancy. The goal is to make the patient visibly disease-free in the abdomen and pelvis.

	Next comes HIPEC, often referred to by doctors as a "shake and bake," and by the media as a "hot chemo bath." HIPEC involves the distribution of cytotoxic drugs, such as mitomycin C -- heated to a maximum of 107.6 F -- throughout the abdominal cavity, ideally killing any microscopic disease that remains. While Sugarbaker distributes the drugs internally with his hands, some doctors prefer to close the abdomen, pour the chemo in through tubes, and then manipulate the peritoneum from the outside to help distribute the cytotoxics (figure, top). Sugarbaker also includes some systemic chemotherapy during the procedure and for several days afterward.

	The treatment regimen ends, Sugarbaker said, with any necessary reconstruction within the abdomen, such as small bowel anastomosis or visceral resections, along with sutures.

	Retrospective data collected by Andrew Lowy, MD, who performs the procedures at the University of California, San Diego Medical Center, show a 1.5% mortality rate and a 1 in 3 complication rate for his CRS and HIPEC patients.

 sought opinions from 2 nurses about the value of cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC).

 Debbie Soldano, RN, BSN, OCN, is an administrative nurse in the Division of Surgical Oncology at the University of California, San Diego Medical Center, which offers the 2 treatments. She supports the work of Andrew Lowy, MD, who performs the procedures there.	

 Theresa McDonnell, ACNP-BC, is nursing director for the cancer center's outpatient clinic at Massachusetts General Hospital. She works with David P. Ryan, MD, who has publicly expressed skepticism about the evidence available to support the use of the procedures.

What have you observed in your patients following the procedures?

 Our average length of stay is 9 days. In the hospital, and when they get out and are recovering, patients feel like they were hit by a Mack truck. Complications can include pulmonary embolism, fever, or bowel obstruction. After the procedures, if you ask patients whether they'd make the same choice again, they wouldn't agree. But later they'd all say yes, because of the benefit.

 It's a big surgery, and they have huge incisions, complicated post-op care, and nutrition and healing issues. It's heart-wrenching, sometimes, to see how sick they can get, and when (their cancer) almost immediately recurs, it's very difficult.

 If we can remove their disease, these people do really well -- better than what they think they're going to do. One of the patients we first treated in Cincinnati had a lot of disease. Six years later, he had a recurrence. Dr Lowy went back in to operate and found that the recurrence was only in 1 area -- the belly was pristine. This man who had appendix cancer and had disease all over everything 15 years ago, is still alive today.

 I personally have not seen any successes. We took care of a young man who had a big surgery and hot chemo for small bowel cancer and ended up with impaired wound healing. He was unable to eat, so we were feeding him through an IV -- not because of his surgeon, but because he had a tough postoperative course. His disease came back almost immediately, and we had to treat him with traditional chemo anyway. I think he was going to die [in any case], but I don't think his quality of life was as good as it could have been had he not undergone surgery.

Should physicians perform CRS and HIPEC, despite the lack of a definitive phase III clinical trial?

 There are a couple of retrospective studies that show that people who had surgery with HIPEC have done incredibly well and are living longer than people who had not had it done. You can give people chemo and they have some response, but it doesn't always address all the disease in their belly -- you can only address that through surgery. I'm in favor of anything that helps patients, and I really believe that this does. I've been doing it for 15 years, and it's a definite fact.

 When patients have heard about potentially curative surgeries and ask, "Should I go?" we always say go for the evaluation, but there's a disconnect, because there's no data for us to share. Having taken care of young, dying patients following these surgeries, you gain a little perspective into the window of the human soul. People will do anything if they think there's a chance they'll spend extra time with their child, wife, or loved one. We need to be very careful when offering these big therapies that we're absolutely positive that outcomes show that the potential benefit outweighs the risks.

What should guide practitioners and patients who are considering CRS and HIPEC?

 A multidisciplinary approach that could include chemotherapy or radiation -- sequence it for the best patient outcome. Patients considering CRS with HIPEC should only go to doctors who have experience with this. And always, before you have surgery, take time to check things out.

 My personal bias would be to start these patients with a multimodality consult. They would see the medical oncologist and surgeon, and we'd then start with traditional chemo. Once we had proof that we'd gotten some effect with that, then we could consider surgery -- debulking and intraperitoneal chemotherapy. It's a major procedure to put a patient through without evidence, but if it turns out after studies that we should do it, then by all means we should start rolling it out to our academic institutions.

	Together, the 2 procedures are generally accepted as the standard of care in several rare cancers -- appendix cancers, pseudomyxoma peritonei and peritoneal mesothelioma, Sugarbaker and Lowy agree. Because those diseases affect small numbers of patients, the doctors said, it is unlikely there will ever be studies conducted to confirm that the methods work. But with colon cancer, which affects more patients and is the most common cause of peritoneal carcinomatosis, there is greater disagreement in the oncology community.

	Five years ago, in a consensus statement, the Peritoneal Surface Malignancy Group, consisting of 72 surgical oncologists from 55 cancer centers in 18 countries, wrote that "systemic treatment alone is no longer appropriate for patients with limited peritoneal dissemination from primary or recurrent colon cancer. A clinical pathway for the management of these patients should include cytoreductive surgery and HIPEC as part of a multidisciplinary approach." Signers of the statement included the Walter Reed Army Medical Center in Washington, DC, the University of Medicine and Dentistry of New Jersey, and the National Cancer Institute in Bethesda, Maryland.

	However, despite this statement and patient testimonials, there is still a demand for proof that the double procedure brings better results than the current standard of care, conventional chemotherapy.

	To Sugarbaker, the call for evidence seems ironic for 2 reasons. First, he said, with the exception of 3 small evaluations conducted by surgeons, there are "no studies that establish efficacy for the treatment of peritoneal metastases from colorectal cancer with modern systemic chemo." Second, Sugarbaker is satisfied with the evidence provided by a randomized study of CRS followed by HIPEC (

. 2003;21[20]:3737-3743), whose results were reported in 2003.

	Ryan says the study showed only minimal survival benefit, was not properly controlled because it included patients with >1 cancer type, and failed to specify which cytotoxic agents were used. Sugarbaker disagrees, saying the study of 105 patients with colon and appendix cancers, run by Vic J. Verwaal, MD, of the Netherlands Cancer Institute, "randomized a little over 100 patients, and was very successful. It showed that patients lived twice as long if they got these procedures as compared to the standard of care: systemic chemo."

	While no other randomized studies of the 2 techniques have been completed, Sugarbaker says there is abundant evidence that the procedures are effective.

	Some of that support was generated in 2009 by Dominique Elias, MD, PhD, of the Institut Gustave Roussy in France, and his fellow researchers. Their study (

. 2009;27[5]:681-685) compared the outcomes of patients with colorectal adenocarcinoma, some treated with systemic chemotherapy and others with CRS followed by HIPEC. The conclusion: "Patients with isolated, resectable peritoneal carcinoma achieve a median survival of 24 months with modern chemotherapies, but only surgical cytoreduction plus HIPEC is able to prolong median survival to roughly 63 months, with a 5-year survival rate of 51%."

	In an attempt to find out once and for all if the procedures can prolong survival, doctors in France are enrolling patients in a randomized, controlled study, Sugarbaker said. All participants will undergo cytoreduction, but only some will have HIPEC, the doctor said.

	Meanwhile, a 340-patient, phase III randomized, controlled, multicenter clinical trial (

) has been enrolling patients in the United States. The trial will analyze the results of systemic chemotherapy versus CRS with HIPEC followed by systemic therapy, in patients with limited periteoneal carcinomatosis that stems from colorectal cancer.

	So far, accrual of patients has been slow. Lowy said enrollment may improve now that the trial is open to patients who have previously undergone a chemotherapy regimen for their disease. Also, patients who fail the systemic chemotherapy regimen will be allowed to switch to the surgical group.

	But Sugarbaker said many will still avoid the trial for fear they won't be initially chosen to receive CRS with HIPEC."If I were a patient, I would not enter that study," he said.

	Due in part to the paucity of clinical data, there is a lack of standardization in the availability, insurance coverage, and costs associated with CRS followed by HIPEC.

	In all, about 120 treatment centers in the United States, 30 each in France and Germany, 5 in Holland, and many in Australia and Japan, offer the procedures, Sugarbaker said. That means that the majority, however, do not.

	Additionally, many insurance companies refuse to cover the double procedure. A clinical policy bulletin on hyperthermia in cancer therapy from health insurer Aetna, last reviewed in June, says the company considers CRS combined with HIPEC medically necessary for the treatment of pseudomyxoma peritonei and peritoneal mesothelioma, but experimental when used to treat other causes of peritoneal carcinomatosis, including colon or ovarian cancers. Similarly, a September policy statement by Cigna said that the company covers HIPEC in combination with CRS only for pseudomyxoma peritonei.

	HIPEC involves the distribution of cytotoxic drugs, such as mitomycin C -- heated to a maximum of 107.6 F -- throughout the abdominal cavity, ideally killing any microscopic disease that remains.

	With the lack of availability and insurance coverage, the costs associated with the procedure are highly inconsistent, according to Laurie Todd, a patient advocate who successfully underwent the procedures while battling Stage IV appendiceal cancer. Todd knows of 1 doctor who charges $383 for a consultation about whether CRS and HIPEC will make sense for a patient. Another doctor charges $25,000 for the same service. Where 1 doctor charges $2000 for HIPEC, another charges $20,000. Her own surgery, HIPEC, and hospital stay carried a price tag of $345,000.

	Sugarbaker hopes these issues are resolved soon and that CRS followed by HIPEC becomes a standard treatment that is routinely considered by teams of doctors treating patients with peritoneal metastases.

Cover Story

There is an ongoing debate in the oncology community about a treatment technique that involves cutting all visible cancer out of the abdomen and then flooding the cavity with heated chemotherapy drugs. The procedure -- known as cytoreductive surgery (CRS) -- followed by hyperthermic intraperitoneal chemotherapy (HIPEC), or a 

Chemo Controversy: An Inside Look at the 'Hot Chemotherapy Bath'

		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

	In January 2011, the American Society of Clinical Oncology (ASCO) published a policy statement on end-of-life care. The authors of the statement noted that care for these patients should include an individualized assessment of the patient’s needs, goals, and preferences. They cited evidence that suggested that realistic conversations about prognosis, the potential benefits and limitations of disease-directed therapy, and the potential role of palliative care, either in conjunction with or as an alternative to disease-directed therapy, occurred late in the course of illness or not at all. It is ASCO’s vision that communication with patients with advanced cancer is improved and that patients are referred for hospice or palliative care earlier. Accordingly, in conjunction with its statement, ASCO released a comprehensive guide for patients with advanced cancer (available to download at 

	These steps are encouraging. People with advanced cancer should be told what end-of-life care choices are available earlier in the course of their disease. But is this happening? The ASCO policy statement has been out for about a year, yet I’m hearing too many stories of patients who were only told about palliative care and/or hospice when they were very near the end of their lives. One oncologist told me that he does not refer any of his patients for palliative care because it “only makes the patient depressed” and takes away hope.

	Oncology nurses are the ones who see the flip side; we care for the patients and families who often are stunned when the patient’s symptoms intensify and the family is left to their own resources to cope and manage the symptoms. I often wonder how much better the patient’s quality of life would have been if only palliative care had been offered sooner.

	Patients need to be empowered and need to know that there are many ongoing and end-of-life care options available to them. The ASCO policy authors estimated that fewer than 4 in 10 patients with cancer are having candid discussions about all of their treatment options.

	Part of the confusion about palliative care and hospice is that patients and their families generally don’t understand these terms. A common misconception is that a hospice is a physical place, as opposed to a specialized type of care. When oncology healthcare providers talk about the services and care (eg, care focused on managing symptoms, care in the patient’s home, nurses visiting the home), patients and their families are often more receptive and interested in palliative care and hospice services.

	In some settings, palliative care referrals are made earlier rather than later when criteria for referral are met. For instance, a patient with advanced disease with functional decline, weight loss, loss of appetite, etc, would be eligible for a palliative care referral either by self-identifying the need for a referral, or via referral from a healthcare provider.

	Interdisciplinary rounds also help educate staff about palliative care and hospice. Interdisciplinary rounds identify patients with advanced cancer who may benefit from palliative care and hospice services, and benefit earlier rather than later.

	I often wonder how much better the patient’s quality of life would have been if only palliative care had been offered sooner. ”

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

	There are also significant cost savings associated with hospice care: hospice care at home costs about $200 per day, compared to $8000 or more for acute care.

	The recommendations from the ASCO policy are still current and include the mandate that quality of life needs to be a priority in advanced cancer care. Oncologists need to talk with patients with advanced cancer about their prognosis and palliative care/hospice options. Lastly, the ASCO policy authors state that patients with cancer—even those with advanced disease&mdash;should be referred to clinical trials when indicated and desired.

	Peppercorn JM, Smith TJ, Helft PR, et al. American Society of Clinical Oncology Statement: Toward Individualized Care for Patients With Advanced Cancer. 

Nurse's Notes

People with advanced cancer should be told what end-of-life care choices are available earlier in the course of their disease.

December 2011

Oncology Nurse Perspectives on Developments in Cancer Care

Nonmyeloablative Conditioning Before Cell Transplantation Shows Potential in Older Patients With Hematologic Malignancies

2011 in Review: NCONN Continues to Change the Face of Cancer Care

Chemo Controversy: An Inside Look at the 'Hot Chemotherapy Bath'

Advanced Cancer Care: Is It Real Care if It Comes Too Late?