As the year 2020 comes to a close, health care providers around the globe may be looking back at the challenges they have faced and the struggles they continue to withstand as the coronavirus disease 2019 (COVID-19) pandemic continues.

Cancer survivors are reflecting, too, and many of them are eternally grateful for the care that they received from their oncology nurses. Our sister publication, 

, asked its readers of patients, survivors, and caregivers about special nurses who made the difficulties of cancer treatment more manageable. The r

, and we featured a selection of them in this issue’s Social Hour column.

Our cover story addresses another global epidemic of decades ago: the spread of 

. Although effective medications allow patients with HIV to live long lives, the disease still poses some challenges in the cancer space, from stigma to drug-drug interactions. Oncology nurses can be instrumental in providing better care for patients with cancer who also have HIV or AIDS.

Also, in this issue, you’ll hear from nurse practitioners on the optimal management of 

 as the space continues to change and more patients and clinicians opt for oral therapies over a trip to the clinic. These nurse practitioners are experts in their field, and those who work in California can now do so without a physician’s oversight. This new legislation brought controversy for some and celebrations for others. Read about it in our Medical Economics article.

Finally, after reading our continuing education section that features updates from the 2020 ONS Bridge Virtual Conference, don’t forget to head online and take the online quiz, worth 1 credit hour.

Oncology nurses rose to the challenges that 2020 brought, and I know that they will continue to strive for the best patient care in 2021 and beyond. Thank you for reading.

Articles

From the Chairman

As the year 2020 comes to a close, health care providers around the globe may be looking back at the challenges they have faced and the struggles they continue to withstand as the coronavirus disease 2019 (COVID-19) pandemic continues.
 

Patients Recognize Nurses' Dedication

Recent years have brought landmark changes for the treatment of patients with human epidermal growth factor receptor 2-positive (HER2+) breast cancer, with the advent of targeted therapies and other new regimens. Therefore, it is essential that oncology nurses have effective approaches to managing this patient population, especially as they receive neoadjuvant or adjuvant dual HER2-targeted therapy.

As if adverse events (AEs) and evolving guidelines were not enough to manage, the novel coronavirus disease 2019 (COVID-19) pandemic also brought about challenges to nurses and clinicians nationwide. Participants in the OncLive® Breast Cancer Talk: Nursing Perspectives on HER2-Targeted Agents in Breast Cancer, discussed these topics. The talk was moderated by Madelaine Kuiper, NP, a nurse practitioner at UCLA Santa Monica specializing in hematology and oncology.

Kuiper was joined by 3 other nurse practitioners: Loyda Braithwaite, NP, from the University of Wisconsin Carbone Cancer Center; Susan Hays, NP, from the Washington University Siteman Cancer Center, and Elahe Salehi, NP, of the Dana-Farber Cancer Institute.

 Please discuss treating your patients who are in the neoadjuvant/adjuvant setting. How often do you see them? Do you do education prior to starting treatment with your patients, and what tend to be the issues that continue? Obviously, adherence to therapy, but particularly at the moment in this current time of COVID-19, how is that impacting your patients’ treatments?

I want to address the adherence to therapy in multiple settings; neoadjuvant, adjuvant, and metastatic. The barriers placed by COVID-19 have been difficult ones. We’re in an area where there are socioeconomic demographics, and racial disparities can impact the patient’s ability to even get to the clinic. And so that has impacted some of our abilities to give and keep them on a regular regimen.

But first and foremost, I think just identifying barriers that keep them away—lack of knowledge, anxiety, transportation issues, all of the things that play into the ability to even get to the clinic.

: Does that then cause problems where you’re seeing patients with more aggressive or larger disease when they present to you?

 We’ve had people that have delayed therapies, and unfortunately, at the height of our pandemic in St. Louis, we were not doing smaller breast tumor cases. Those patients were put on hold, and a determination had to be made whether or not to continue therapy or wait. So yes, I think it has impacted outcomes to a certain extent.

 Elahe, have you anything to add to that about your experiences during this current time?

 At Dana-Farber, we do have pathways for every disease, and we have it for breast oncology patients. And doing the pathways, it’s a combination of the NCCN guidelines and the new practices and new research focused on patient care. With COVID- 19, we did have to change a little bit in the aspect of how we treat our patients with breast cancer and we communicate that actually with everybody, and it’s on our intranet. We tend to use a lot of patients who were able to get sub-q injections for Herceptin rather than bringing them and having an IV infusion with longer duration.

As per how we treat the adjuvant and neoadjuvant setting in our patients, at Dana-Farber, we mostly use anthracycline-based chemotherapies unless there is a contraindication. So mostly our regimens depend on the staging of the cancer, and nose positivity depends on the THP component versus AC-THP or TCHP regarding anthracycline sensitivity.

: Let’s move on now to how we counsel our patients on the common AEs and adverse reactions associated with pertuzumab and trastuzumab. Obviously, there is a variety, usually with naïve patients, so how do we ensure that they know how to handle a lot of these AEs. Loyda, would you like to give us your perspective, please?

I think education is very important for our patients. At our institution, whenever we start a patient either in neoadjuvant or adjuvant treatment, or perhaps for a patient with metastatic disease, we make sure we set up a time with a nurse educator so the patients can have one-on-one time to go through the information. We provide written material and a lot of follow-ups because we anticipate that patients are likely not going to be able to grasp all the information … So make sure that they have preparation beforehand in the education, so it’s likely to be more effective. We anticipate that session happening usually about a week or 2 prior to the initial infusion.

I think we do a combination of phone calls, one-on-one teaching, well, prior to COVID- 19, it was a one-on-one teaching, but we still do a one-on-one but in alternative ways. We make sure there aren’t any last questions to be answered prior to treatment and make sure that we make ourselves very accessible to them too, because I think a big factor when patients start treatment is this uncertainty of what to do if they need to contact [someone.] So I think that reassurance of this is education, but there is also the human factor next to it. It provides a lot of that pathway for patients to be able to access us.

 What would you say are some of the key points or some of the key, I should say, AEs that you tend to cover with your patients in your teaching?

 We make sure patients know about the cardiac toxicity that can come with anti-HER2 treatments; also fatigue and nail changes, which is something that we don’t address but it’s very common and patients can become quite affected and distressed. So [we discuss] that, among the other well-known symptoms, like alopecia and so forth, [which are] not as frequent, but we still see quite a bit of hair thinning, so we make sure that we hit those points for patients and the fatigue among those as well.

Elahe, I’d like you to further expand on the potential cardiac toxicity long-term from these HER2- targeting therapies, and the use of an anthracycline, particularly in the early breast setting. Could you tell us how you treat your patients and how you monitor them?

Our protocol is based on the treatment prior to initiating any anthracycline or HER2-directed therapy. We obtain an echocardiogram to evaluate the ejection fraction of every patient. For adjuvant-setting patients, they will continue on it every 3 months with echocardiograms. In our metastatic population, it depends, but mostly it fluctuates between a 6-month to 12-month period.

We are lucky in our institution. We have an oncocardiologist program that we tend to refer patients, whether they come in with a cardiac dysfunction to begin with, whether they were lymphoma patients who had low body radiation, or whether patients will have a lower ejection fraction due to our treatment. And most of the time, they were seen by these providers urgently. Cardiac toxicity, most of the time, is reversible. So we have some beta-blockers and ACE inhibitors and hold the treatment for a 3-week period and reevaluate patients starting on anti-HER2-directed therapy.

 What advice would you like to give clinicians who are seeing a lot of these new agents now, either in their infusion centers or those who do a lot of education with their patients?

 I would say that I have been an oncology nurse for many years, and I was around in 1998 when trastuzumab was approved. So just seeing how cancer, particularly breast cancer, has evolved over the years has just been an amazing thing to watch. I feel really old. I feel like I’m getting out soon, but I would encourage oncology nurses that this is the best thing you could ever do—it’s the most challenging, it’s the most rewarding. I would say you’re ever learning, ever-growing, and probably will always be touched by the fact that you’re involved in someone’s life, making an impact.

So from that point of view, I would also say that they should take a molecular biology course and a genetics course as part of their educational learning. I feel like I’m on the back end, trying to catch up. But certainly, it’s exciting just to see how things are just moving along.

Professionally Speaking

Four oncology nurse practitioners sat down and discussed the recent developments in the treatment of HER2-positive breast cancer and how to manage this group of patients during a worldwide pandemic.

HER2-Positive Breast Cancer Treatment Continues to Change

The landscape for breast cancer has changed drastically since 2010, with improvement seen in all types of breast cancer.

Historically, human epidermal growth factor receptor 2 (HER2) overexpression was associated with a poor prognosis and an increased risk of recurrent disease, but the recent approvals of 2 oral agents for HER2-positive (HER2+) breast cancer made headlines at national oncology meetings and are improving outcomes for patients.

Tucatinib (Tukysa) is an oral agent studied in combination with trastuzumab (Herceptin) and capecitabine (Xeloda) for metastatic HER2+ breast cancer, including disease with brain metastasis. The research arm with tucatinib decreased the risk of central nervous system progression or death by 68% in patients with brain metastases, compared with the placebo arm.

When administering any new agent, oncology nurses must focus on adverse event management and medication adherence with their patients. Patient education should include treating diarrhea, rash, blisters, nausea, fatigue, and increased liver function. Tucatinib is given twice a day for 21 days with or without food. A challenge for patients is the dosing of capecitabine, which is taken twice daily for 14 days within 30 minutes of food when taken with tucatinib.1 Patients will need verbal, written, and other tools (apps, calendars) to ensure proper dosage of these medications.

A second exciting agent is neratinib (Nerlynx), approved for patients who have completed a course of trastuzumab-based therapy after surgery and chemotherapy. It is used as a single agent in the adjuvant setting.

Neratinib in the extended adjuvant setting is given for 1 year to further reduce the risk of breast cancer recurrence.2 When starting neratinib in the extended adjuvant setting, use a dose titration to assist with diarrhea management.

Fortunately, neratinib crosses the blood-brain barrier and has an indication in combination with capecitabine for the treatment for patients with advanced or metastatic HER2+ breast cancer who have received 2 or more prior HER2-based regimens. In the metastatic setting, neratinib and capecitabine are administered continuously with no breaks throughout the 21-day cycle treatment cycle. This indication for neratinib is in the adjuvant setting where it is given for 1 year to further reduce the risk of recurrence. Patient education should also include oral adherence.

Oncology nurses move with the changing landscape while also providing excellent care to their patients. Thank them for taking on the new challenges and helping patients every day.

Seattle Genetics announces U.S. FDA approval of Tukysa (tucatinib) for people with advanced unresectable or metastatic HER2-positive breast cancer. News release. Seattle Genetics, Inc; April 17, 2020. Accessed October 29, 2020

 Puma Biotechnology Receives U.S. FDA Approval of Supplemental New Drug Application for Neratinib to Treat HER2-Positive Metastatic Breast Cancer [news release]: Los Angeles, CA. Puma Biotechnology. Published February 27, 2019. 

https://bwnews.pr/2I02Xx8. Accessed October 29

Nurse's Notes

When administering oral therapies for HER2+ breast cancer, discuss adverse events and medication adherence.

New Breast Cancer Agents Put Focus on Adverse Events, Adherence

The World Health Organization declared 2020 the International Year of the Nurse and Midwife. Oncology nurses and health care providers everywhere have stepped up and showed their heroism and compassion amid the coronavirus disease 2019 (COVID-19) pandemic. 

, recently asked their readers—cancer survivors and patients&mdash;about how oncology nurses have helped them through their cancer journey. Responses were overwhelmingly positive. Here is what some of them had to say:

"[My nurse] knew something wasn’t right with me, even though my cardiology test [was] normal. She convinced the oncologist to send me to a cardiologist and we found that my heart function was extremely low. We stopped chemo and the cardiologist nursed me back to normal. That was 14 years ago.”

"All [nurses] at my center were wonderful. But one in particular was my ‘regular.’ She knew and understood my style/personality, and we had a blast! Yes, a blast! I actually looked forward to chemo day! They are a special breed. I will forever be grateful!”

"I’m just so happy with everyone I have had. They are great listeners; some have a wonderful sense of humor. If they don’t know the answer to your question, they will get it. They make every trip to the oncologist a lot easier for sure. They are very special people, indeed.”

"Oncology nurses are one of the most important parts of your team when you have cancer. The nurses I have had are immeasurable in their care, compassion, and focus to getting you feeling comfortable in a time when things are so not right.”

"The oncology nurses are what holds everything together. They are the ones who answer your phone call, clear the way to get in for fluids, and give the best hugs—back when hugs were allowed.”

"They are rock stars. When I had my last chemo treatment, they all gathered outside my treatment room to celebrate with me. It is a very special memory.”

The Social Nurse

Oncology nurses do not realize how appreciated they truly are. See the heartfelt thanks that patients shared.

Patients Offer Nurses Words of Thanks

January 2020 marked the beginning of the World Health Organization’s “Year of the Nurse and Midwife,” commemorating the 200th birthday of Florence Nightingale, founder of modern nursing.

Professionals around the globe planned conferences and recognition events to celebrate the nursing profession and Nightingale’s historic accomplishments reducing disease transmission in field hospitals in Crimea.

However, by late February, the growing incidence of the coronavirus 2019 (COVID-19) in China and outbreaks in the United States began to turn attention away from these planned festivities. Seemingly overnight, a massive response to the deadly virus was mobilized by the health care community, with the implementation of lockdowns, remote work, mandatory masking, and countless policy, procedural, and operational changes. What irony, that in a year planned for the global celebration of a 19th-century pioneer in the study of disease transmission and nursing, society instead had to focus all efforts on the containment of a deadly disease spreading rapidly across the globe.

By late spring, the world was in a full global COVID-19 pandemic with the end nowhere in sight. Public health infrastructures proved to be inadequate to support hospitals and health care workers, and without a coordinated national approach, the local level established efforts to control the virus at the local level. Many health care institutions struggled to procure needed personal protective equipment (PPE), cleaning supplies, therapeutics, and mechanical ventilators to care for critically ill patients with COVID-19.

Throughout this unprecedented time in society, oncology nurses have worked tirelessly to provide uninterrupted, life-saving cancer care to patients in hospitals and outpatient settings. Early on, oncology nurses knew that cancer wasn’t going to stop for COVID-19, so neither could they. Along with continuing to provide cancer treatment, oncology nurses had the added challenge of protecting patients and each other from COVID-19 through strict isolation procedures and the use of PPE, which has its origins in Nightingale’s work.

 They acquired new skills to care for immunocompromised patients in special COVID-19 intensive care units. Because of strict no-visitor policies, oncology nurses also became liaisons between patients and their loved ones, holding phones to patients’ ears, and providing daily updates to families at home. Too often, they have been the only human beings in the room at the end of life to assure their patients do not die alone.

In other settings, oncology nurse navigators moved their practice remotely, caring for patients at home through telehealth visits.

Clinical trial nurses innovated standard operations such as shipping investigational drugs to patients’ homes to enable them to safely remain on study. Clinical teams developed mechanisms for virtual huddles to coordinate and assure delivery of the same standard of care excellence previously provided in person. Many of these innovations have proven successful and are well received by patients and families. Efforts are underway to design and test care models that will expand the availability of other cancer services at home. When effective vaccines are available and the pandemic recedes from its current place of prominence, some of these new models will certainly become best practices in cancer care.

Forever influenced by the past 9 months, personal and professional lives have undoubtedly taken an emotional toll. As winter settles in and people prepare for a potential next COVID-19 surge, people must focus on supporting one another and the colleagues who join in this work. Oncology nurses need to find ways to renew and sustain themselves while continuing to care for patients. The heroic efforts of oncology nurses during the pandemic have been frequently highlighted in the media. This is ironic because the commitment to care for patients and families is oncology nurses’ true north, no matter what. It is what they do every day.

In a recent interview on NBC’s Today Show, Kevin Browne, DNP, RN, CNS, CCRN, deputy chief nurse at Memorial Sloan Kettering Cancer Center said it best. “Thank God there are people (nurses) like this in the world who chose these professions—to want to run toward a pandemic, rather than run away from it,” he said.

May all nurses continue to run toward their patients during this time, fortified by self-care and resiliency-building practices to sustain them.

Year of the Nurse and the Midwife 2020. World Health Organization. Accessed October 22, 2020. https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020

Florence Nightingale; Mystic, Visionary, Healer.

Notes on Nursing: What It Is and What It Is Not.

Nurse manager reunites with heroic team who treated him for COVID-19. Today. October 8, 2020. Accessed October 22, 2020. https://www.today.com/video/nurse-manager-reunites-with-heroic-team-who-treated-him-for-covid-19-93423173664

Partner Perspectives

Early on, oncology nurses knew that cancer wasn’t going to stop for COVID-19, and so neither could they.

Oncology Nursing Practice in 2020: The Challenges and Opportunities of the COVID-19 Pandemic

Gretchen McNally, PhD, ANP-BC, AOCNP, microspecializes in immunodeficiency- related cancers. - Photo by Jodi Miller

The current coronavirus disease 2019 (COVID-19) pandemic is not the first instance where nurses have found themselves caring for patients with a mysterious and unpredictable disease. In the early 1980s, hospitals around the world began to see patients, primarily young gay men, presenting with severely compromised immune systems, rare cases of pneumonia, and aggressive cases of Kaposi sarcoma, a cancer that causes lesions in the soft tissues.

At the time, clinicians and investigators had no idea what caused the outbreak, how the virus was transmitted, or how it should be treated. Some referred to the disease as the "gay cancer" or "gay-related immune deficiency." It wasn’t until 1983 that HIV was identified as the cause of AIDS and investigators recognized that HIV could affect anyone.

Today, 40 years after the beginning of the HIV/AIDS outbreak, oncology nurses continue to care for patients with AIDS-related and nondefining AIDS cancers.

Research shows that individuals with HIV/AIDS are at a higher risk of getting certain types of cancer because they have a severely weakened immune system.

Although advancements in antiretroviral medicines now allow those with HIV/AIDS to live longer lives, many of these patients continue to face barriers to cancer care and, in some cases, a stigma that can negatively affect their health outcomes.

Gretchen McNally, PhD, ANP-BC, AOCNP, a nurse practitioner in hematology at The OSUCCC — James in Columbus, Ohio, microspecializes in immunodeficiency-related cancers and says nurses play a critical role in ensuring that patients fighting both HIV/AIDS and cancer receive inclusive services and care.

HOW AIDS-DEFINING AND NON—AIDSDEFINING CANCERS DIFFER

McNally notes that when patients with HIV develop certain types of cancer, their disease has progressed to AIDS.

Gretchen McNally, PhD, ANP-BC, AOCNP, microspecializes in immunodeficiency-related cancers. “These cancers are known as AIDS-defining cancers and include Kaposi sarcoma, aggressive forms of non-Hodgkin lymphoma, and cervical cancer,” she says. “Some patients with HIV are also more likely to develop non—AIDSdefining forms of cancer, but these forms of cancer don’t indicate that their condition has progressed to AIDS.” McNally adds that non–AIDS-defining cancers include head and neck cancer, anal cancer, lung cancer, liver cancer, and Hodgkin lymphoma.

“While AIDS-defining cancers have decreased with effective combination antiretroviral therapy, non—AIDS-defining cancers have increased and account for more than half of all HIV malignancies,” McNally says. “Because people with HIV have a compromised immune system, they’re also more at risk of viruses that can lead to cancer such as the human papillomaviruses [HPV].”

HPV is linked to cancers of the penis, anus, vagina, vulva, mouth, and throat. Although advances in antiretroviral therapy have resulted in HIV being treated as a chronic health condition, McNally says because those with HIV/AIDS are living longer, their increased life span also increases their risk of developing cancer. Approximately 1.2 million individuals in the United States are currently living with HIV.2

Although it’s been more than 40 years since health care professionals first treated cases of HIV and AIDS, stigma and discrimination still persist in health care. In 2018, the Centers for Disease Control and Prevention released a review analyzing HIV-related stigma by health care providers.3 Among their findings, investigators reported that stigma can be manifested through inadvertent behaviors and beliefs, including homophobia, transphobia, racism, and negative views of people who use drugs.

“The solution to reducing any stigma is education,” says McNally, who has seen the stigma of HIV transcend to both health care providers and patients.

“Some patients suffer from depression because they believe an HIV diagnosis was their fault,” McNally says.

To fully understand the needs of their patients with HIV/AIDS and help reduce the stigma, McNally says, health care providers must expand their knowledge on issues such as sexual orientation, gender identity, and racial disparities. Although the United States has a policy goal of eradicating HIV by 2030, disparities in HIV care continue to exist.

“We’ve been seeing more cancers, including Hodgkin lymphoma and lung cancer, in younger patients,” McNally says. Statistics show that lung cancer is already a leading cause of death in those with HIV, particularly among individuals who smoke, and it is projected to become the most common cause of cancer in individuals with HIV by 2030 if current trends continue.

To combat rising rates and help patients with HIV reduce their cancer risk, McNally says, health care providers should emphasize prevention and address risk factors. Nurses can do the following:

• Recommend smoking cessation programs to those with HIV to possibly reduce their risk of lung cancer and other tobacco-related diseases.

• Educate patients on the importance of regularly taking their HIV medications. Maintaining a higher CD4+ T-cell count can reduce the risk of AIDS-related cancers.

• Encourage patients to get the HPV vaccine. “The vaccine has been shown to prevent anal and cervical cancers,” McNally says.

TREATMENT CONSIDERATIONS FOR PATIENTS WITH HIV/AIDS AND CANCER

In 2018, a team of health care providers gathered to create new National Comprehensive Cancer Network (NCCN) treatment guidelines to ensure individuals with HIV who also have cancer receive safe and necessary treatment.

Piera Wong, MS, RN, AOCNS, an oncology clinical nurse specialist at Zuckerberg San Francisco General Hospital and Trauma Center and an assistant clinical professor at the University of California, San Francisco, says nurses and physicians at her facility continue to follow these guidelines.

“We have a board-certified oncology pharmacist review all proposed cancer therapy and antiretroviral medications to ensure there aren’t any drug[-drug] interactions,” Wong says. “We also follow patients closely from diagnosis to treatment through survivorship.”

Wong stresses that nurses should also address preventive care with patients, encouraging patients to adhere to annual screenings such as colonoscopies, pap smears, and skin cancer checks.

Ensuring that patients with HIV have access to appropriate cancer care is also a priority. One recent study found that individuals living with HIV have lower rates of cancer treatment, which may contribute to worse survival rates in certain cancers. The study also found that barriers to care sometimes include low income, no insurance or underinsurance, employment instability, lack of social support, and HIV-related stigmas.

Yet even with appropriate treatment, Wong says, some patients with both HIV and cancer experience poor outcomes. A study published in 

 found that outcomes for patients over age 65 with HIV and cancer were significantly poorer than patients who were the same age and HIV negative. The study suggested the higher mortality risk was because of immune suppression.

“This is one reason why it’s so important to allow [patients with] HIV to enroll in clinical trials,” McNally says.

Although patients with HIV were excluded from cancer clinical trials in the past, that appears to be changing. Last year, a study conducted at Fred Hutchinson Cancer Center in Seattle, Washington, found that patients with HIV and cancer might be successfully treated with the immunotherapy drug pembrolizumab (Keytruda).

Last year, the National Cancer Institute issued new guidelines for patients with HIV and clinical cancer trials. The guidelines state that individuals who are HIV positive should not be arbitrarily excluded from clinical trials.

The guidelines state that “with effective antiretroviral therapy, individuals with undetectable HIV viral loads by standard clinical assays should generally be considered eligible for a study should they meet all the other eligibility criteria of the trial.”8 “The hope is these new guidelines will ensure all [patients with] cancer who are HIV positive can achieve the same outcomes as those without HIV,” McNally says.

Cover Story

Nurses can take several steps &mdash; from stigma reduction to treatment considerations &mdash; to improve the care of patients with cancer who have HIV or AIDS.

December 2020

Patients Recognize Nurses' Dedication

HER2-Positive Breast Cancer Treatment Continues to Change

New Breast Cancer Agents Put Focus on Adverse Events, Adherence

Patients Offer Nurses Words of Thanks

Oncology Nursing Practice in 2020: The Challenges and Opportunities of the COVID-19 Pandemic

Break Down Barriers to Cancer Care for Patients With HIV/AIDS