Cancer is a widespread disease that affects every population, yet none more so than the elderly. This patient population is growing at a pace that is overburdening cancer centers, and the duty of filling the gap created between aging patients and their care team is falling on oncology nurses.

Although there already is a shortage of nurses, even fewer are geriatric certified, making these training programs vital to the future of the oncology nursing field.

To understand the full scope of the care gap nurses are faced with bridging, it’s important to understand the phrase the “Silver Tsunami.” This nickname refers to the rising tide of the aging population flooding the healthcare system. On average, 10,000 Americans turn 65 each day, and 53.4% of all new cases of cancer involve patients 65 and up, with a median diagnosis age of 66, according to the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program 2019 statistics.1

“The last of those baby boomers, those born between 1946 and 1964, will be turning 65 in 2030. And the estimate is [that] 1 in 5 of these baby boomers will be over 65 in 2030, so that’s a big group of people coming into the healthcare system in 2030,” explained Carolina Uranga, MSN, BSN, RN, AGCN-BC, OCN, WCC, ONS, in an interview with Oncology Nursing News®. However, healthcare has long known that the silver tsunami would crest in 2030.

Uranga, a clinical nurse specialist at City of Hope in Los Angeles, California, added that the majority of patients that nurses will see in a cancer clinic are elderly adults, and although 2030 feels far away, the gap in care is happening now and colliding with the current oncology nursing shortage.

“According to Dr Buerhaus in his article ‘Four Challenges Facing the Nursing Workforce in the United States,’ the acceleration of nurses retiring is estimated to be 1 million by 2030,” and this will create a brain drain in the healthcare system,” Uranga said.2 “Suffice to say, we aren’t graduating enough nurses also to keep up with the estimated demand. It’s really a vicious cycle because we don’t have enough nursing professors to provide the education, so we really can’t graduate enough nurses to keep up with the demand.”

Uranga pointed out that although less than 1% of nurses are geriatric certified, more schools are adding geriatric training to their programs, allowing all specialties within oncology to get the training they need to properly assess elderly patients.

A patient is considered geriatric at 65 because at this age, Social Security and Medicare benefits kick in, but this chronological age does not always equate to a patient’s functional age, according to Uranga.

At the 37th Annual Chemotherapy Foundation Symposium (CFS®), hosted by Physicians’ Education Resource®, Uranga presented on a geriatric training and assessment program done through City of Hope that recently received Cancer Research Education Grants Program (R25) support for a funding effort that her and her colleagues were spearheading.3

One of the program’s pillars involves educating nurses to understand that age 65 does not have to be a medical cutoff for treatments and that patients younger than 65 may function worse than someone older. Each patient is different, with a different cancer, so the care they need will be unique.

“Maybe [with a] patient you thought you couldn’t be aggressive with, you do a geriatric assessment…and find that this patient can tolerate an aggressive treatment versus decreasing the dose,” Uranga explained during her presentation. “Some older patients can do a lot more and are very active, so assessing the fitness of the older adult versus their frailty will go a long way in making those decisions.”

This approach to personalized care for geriatric patients has also changed the oncology nurse’s role at the bedside. In an interview with Oncology Nursing News®, Paola Bueno, RN, a clinical nurse at City of Hope and a participant in the R25 grant program, discussed how she approaches geriatric patients. “We perform some assessments that help determine any age-related sensory changes that patients might have, such as auditory [or] visual, or limitations on mobility,” she said.

Implementing these tests has led to a better workflow, Buneo said, because it gives the care team a validated tool that can help create personalized care plans prior to undergoing the rigors of cancer treatment. These assessments are often not time-consuming and are simple for the patient to use. For example, the Timed Up & Go assessment takes 3 minutes or less, and nurses need just a chair, a stopwatch, and 10 feet of space. The nurse times the patient walking 10 feet from the chair and back; according to the certified test, 12 seconds or more indicates a risk of falls and also gives the nurse the chance to observe the patient’s gait and consider how adverse effects from treatment might affect mobility.3

Ultimately, Uranga and Bueno hope that a better understanding of what it takes to help a geriatric patient will lead to more positive outcomes as oncology nurses bear the brunt of the Silver Tsunami.

Articles

Feature Story

As the number of elderly oncology patients rises rapidly, nurses need training to properly assess their needs.

Nurses Face Challenge of Closing Gap in Geriatric Care

As we make our way into 2020, it is important to reflect on all the opportunities and achievements of last year. As oncology nurses, take a moment to exam your goals for professional and educational development. I challenge you to make this a year of professional growth geared to optimize the care you provide patients and families.

Did you know that, according to the Leukemia & Lymphoma Society, every 3 minutes, someone receives a diagnosis of a blood cancer, which accounts for 10% of all cancers? In 2019, an estimated 176,200 people were predicted to receive diagnoses of leukemia, lymphoma, and multiple myeloma. Among these cases, 56,770 were expected to die as a result of their disease.

Given these statistics, conferences such as that of the American Society of Hematology (ASH) are held each year to educate clinicians and scientists working in the field of hematology. In December 2019, ASH celebrated its 61st anniversary, which included recognizing evolutions in acute and chronic leukemia, multiple myeloma, lymphoma, stem cell transplantation, chimeric antigen receptor (CAR) therapy, and many more.

The E. Donnall Thomas Lecture and Prize was awarded to Philip Greenberg, MD, for his research using T cells to treat patients with acute myelogenous leukemia (AML) and solid tumors. For over 3 decades, the only curative treatment for AML has been conventional chemotherapy and allogeneic transplantation. According to the National Cancer Institute, the 5-year survival of patients with AML is 27.4 %.

Innovations such as adoptive cell therapy offer promising outcomes, given their selectivity to T-cell receptors.

Other exciting advancements in the field include the following:

Blinatumomab (Blincyto), a bispecific T-cell antibody, was proved to be effective in sustaining diseasefree survival, overall survival, and the ability to proceed to transplantation in relapsed/refractory (R/R) acute lymphoblastic leukemia.

The bispecific humanized immunoglobulin that targets CD3 and CD20, mosunetuzumab, showed an overall response rate of 64.1% and a 42.2% complete remission rate in patients with indolent non-Hodgkin lymphoma who were re-treated with the agent after CAR T-cell therapy.

A phase I study of CAR T-cell therapy for patients with R/R multiple myeloma showed a median response of 28.8 weeks.

The field of oncology is rapidly expanding with clinical trials, newly approved pharmacological agents, and precision medicine. As nurses approach the future, a commitment to lifelong learning will be essential to remaining competent. We will need to provide multimodal teaching to ensure that patients understand their treatments, including adverse events. Patients and families depend on their nurses to be knowledgeable experts in their care.

The evolution of population health has expanded the settings in which oncology patients receive treatment. These settings include hospitals, outpatient clinics, and day treatment centers. It is essential that nurses anticipate the needs of patients who receive treatment in nontraditional settings. This includes offering comprehensive discharge instructions, providing emergency contact information, and discussing which symptoms to report. Given the advanced age and complexity of patents with cancer, ongoing reinforcement of the treatment plan is critical to minimizing complications that lead to increased mortality.

Facts and Statistics. Leukemia & Lymphoma Society website.lls.org/facts-and-statistics/facts-and-statistics-overview/facts-and-statistics. Published 2019. Accessed January 3, 2020.

Cancer stat facts: leukemia — acute myeloid leukemia. National Cancer Institute website. 

Brown PA, Ji L, Xu X, et al. A randomized phase 3 trial of blinatumomab vs. chemotherapy as post-reinduction therapy in high and intermediate risk (HR/IR) first relapse of B-acute lymphoblastic leukemia (B-ALL) in children and adolescents/adults (AYAs) demonstrates superior efficacy and tolerability of blinatumomab: a report from Children’s Oncology Group Study AALL1331. Presented at: 61st American Society of Hematology Annual Meeting & Exposition; December 7-10, 2019; Orlando, FL. Abstract LBA_1. bit.ly/2LDMr7U.

Schuster SJ, Bartlett  NL, Assouline S, et al. 

Mosunetuzumab induces complete remissions in poor prognosis non-Hodgkin lymphoma patients, including those who are resistant to or relapsing after chimeric antigen receptor T-cell (CAR-T) therapies, and is active in treatment through multiple lines.

 Presented at: 61st American Society of Hematology Annual Meeting & Exposition; December 7-10, 2019; Orlando, FL. Abstract 6. ash.confex.com/ash/2019/webprogram/Paper123742.html.

Li C, Mei H, Hu Y, et al. A bispecific CAR-T cell therapy targeting Bcma and CD38 for relapsed/refractory multiple myeloma: updated results from a phase 1 dose-climbing trial. Presented at: 61st American Society of Hematology Annual Meeting & Exposition; December 7-10, 2019; Orlando, FL. Abstract 930. bit.ly/38imXXG.

Nurse's Notes

"As nurses approach the future, a commitment to lifelong learning will be essential to remaining competent."

Nurses, Set Goals in the New Year

Annette Galassi, MA, BSN, OCN - photographed by Claudio Papapietro

In November 2011, Annette Galassi, MA, BSN, OCN, traveled to Ethiopia with the organization Health Volunteers Overseas to help start a new project. She had long wanted to volunteer and had a growing interest in oncology nursing in low-resource settings. When she ran across an advertisement in an oncology publication looking for nurses and doctors to volunteer, Galassi was in the right place in life and ready to commit. She followed the pull and applied.

Communicable diseases were coming under control in many places. People were living longer, but more were developing cancer.

 Access to cancer care was a growing problem, and Galassi wanted to help.

“Ethiopia had a population of 90 million people. They had 1 public hospital with 2 cobalt radiation machines for the entire country,” Galassi said in an interview with 

. “Patients presented with latestage, often incurable disease. Nurses had little or no personal protective equipment, and they would mix chemotherapy right at the bedside. Resources, supplies, and medication were extremely limited, as was knowledge about cancer and cancer care.”

Galassi made several trips to Ethiopia to help educate and train the nurses, and she and a colleague work with the school of nursing to draft a certificate program in oncology nursing. She sees a silver lining in partnerships like the one between the Addis Ababa University School of Nursing and Midwifery in Ethiopia and the University of Oslo in Norway to offer an oncology master’s program.

The issues facing low- and middle-income countries (LMICs) are complicated and multifactorial. Problems such as political and financial barriers to cultural views on cancer, as well as the undervalued role of nurses, can seem insurmountable.

But nurses such as Galassi, along with volunteer healthcare organizations that provide collaborative, sustainable programs and tailored approaches to problem solving, are leading to desperately needed improvements in cancer care. One top priority for oncology nurse volunteers is providing education and training for nurses, who provide most of the cancer care. Nursing education typically does not include training on cancer.

 Standards and protocols are often inconsistent or nonexistent.

Most patients in LMICs purchase their own chemotherapy medications and bring them to the hospital. By insisting that the nurse stay at the bedside to mix the drugs, they know they are getting what they paid for. Patients also pay for supplies out of pocket, and expect them to be resused.

Showing senior nurses how to perform skills and assessments and teaching them to instruct less experienced staff helps all involved grow and build confidence.

Some nurses may see patient education as the doctor’s responsibility and not realize that patients may need to hear information several times before they remember and understand or that, patients may feel more comfortable asking questions of a nurse than a doctor.

In many countries, nursing is not considered a prestigious profession. Galassi, who is involved in volunteer work with a pediatric oncology unit in Delhi, described the situation in India: “Nurses are often looked down upon and not treated as equal. This can get in the way of moving their practice forward.” She said her team worked hard to get nurses to competently assess and present patients’ problems to physicians, rather than passively taking orders, doing whatever the physician said, and never questioning anything.

“Physicians needed to understand that although they could teach about the disease process and action of drugs, they didn’t have the nursing expertise to teach nursing at the bedside, nursing assessments, [or] nursing interventions or how to conduct a root cause analysis for spikes in PICC [peripherally inserted central catheter] line infections, figure out potential reasons, and figure out what could be done to change things,” Galassi said.

Galassi, who continues volunteering in places like Bhutan and India, encourages nurses who are interested in global volunteer work to do their research when selecting an organization with which to partner.

Virginia LeBaron, PhD, APRN, ANCP-BC, FAANP, wholeheartedly agrees. LeBaron and Galassi coauthored a resource article for nurses interested in volunteering.

In 2004, LeBaron was working as an oncology nurse and palliative care nurse practitioner. She had always been interested in global health work, but struggled to find the right organizational fit. She eventually connected with a global oncology group working in partnership with countries to build palliative care capacity. It was a perfect match, and LeBaron made her own eye-opening first trip as a global oncology nurse volunteer in Nepal.

The volunteer organization’s work was based on sustainable partnerships, and they collaborated with healthcare providers to tailor their approach. LeBaron became involved in education about capacity building related to palliative care.

There were (and are) huge disparities in access to basic pain medicine.5 She worked in hospitals and saw that patients with late-stage cancer were unable to get prescriptions for morphine.

“There are multifactorial issues regarding pain medication,” LeBaron told 

. “There is a physical lack of supply of opioids. This lack is perpetuated and exacerbated by regulations that make if difficult for providers to prescribe medication or for pharmacies and formularies to stock medication.”

These factors contribute to what appears to be low demand, creating a cycle of inability to create enough supply, she said: “It circles back to regulations. Low demand is not lack of need. Need is great; supply and access are low.” Even when opioids are accessible, they may not be in the correct form. Intravenous (IV) morphine is not helpful for patients who need oral medication for home use.

Pain management and access to pain medication are issues not only in Nepal but also in many other low-income countries. For LeBaron, knowing that patients’ pain was not adequately managed set her on a path to explore how to improve that situation. She started working with other organizations related to pain management and policies around opioids. Around the same time, as she was completing her dissertation on access to opioids and pain management, issues began emerging about the opioid epidemic in the United States. Her research was caught in the crosshairs of patients suffering in agony without pain medication and the significant concerns about misuse and diversion of opioids.

“It is an interesting place to be,” she recalled. “People are asking, ‘How do we achieve balance between not putting patients and communities at risk but, at the same time, not contributing to the undertreatment of pain or stigmatizing opioid therapy for people who legitimately needed it?’” Now, in the United States, data are emerging about patients’ difficulty in accessing necessary pain management and the unintended effects of good-intentioned regulations. “Global health work is colliding with what’s happening domestically,” LeBaron said.

Lori Buswell, NP, MS, is the executive director at the Dana-Farber Cancer Institute’s Center for Global Cancer Medicine, which was established in 2012 and, alongside the nonprofit group Partners in Health (PIH), supports the advancement of cancer care in LMICs. She shared with Oncology Nursing News® about the work she has been involved with in Rwanda.

“In 2012, the center, PIH, and the Rwandan Ministry of Health kicked off a national weeklong training course for doctors and nurses throughout the country to raise awareness of what cancer is, what it looks like, and how it is treated. In-depth training was provided for hospitals that treat patients with cancer. Most of the chemotherapy was given at a hospital in Butaro because the drugs were free—PIH paid for them&mdash;or [at] the private hospital for patients who had money, could purchase the drugs, and be treated. There were only 2 places where people could get chemo and only 1 oncologist in the entire country. Now there are 4 [or] 5, although they are all in the capital city. The first radiation center didn’t open until 2019. Before then, patients were sent to Uganda and Kenya for radiation, also paid for by PIH.”

Volunteers from several cancer centers work in Butaro for a couple of weeks to teach nurses and physicians, including general practitioners, about oncology and how to take care of patients, Buswell said. They provide protocols for treating patients with cancer—how to work up, stage, and treat them. “Cancer is an interdisciplinary team event. We try to build expertise in all disciplines,” she said.

Buswell travels to Rwanda twice a year for 4 to 8 weeks. The volunteers help write policies and procedures to solidify what nursing practice should look like and encourage efficiency.

“One thing we did was to write down all the elements needed to administer chemo,” Buswell said. “Now they have a standard template for the patient to bring to the pharmacy and get everything needed.”

Although the need is great, opportunities are limited for volunteers, and it is important for nurses to realize that meaningful work requires an investment in time. “Volunteers who drop in for a week or 2 have helped a patient but haven’t helped the country build a workforce,” Buswell noted. Sending tubing, IV pumps, or 100 doses of medication also is not necessarily helpful. The real needs: sustainable partnerships and donations of time and money.

Buswell believes that it will take a couple of generations or more to get essential workforces in place. “There is great satisfaction, however, in paying it forward,” she said. “Global oncology volunteer work is incredibly satisfying on a personal and a professional level.”

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Galassi A, Morgan C, Muha C. Making the invisible visible: oncology nursing efforts of NCI-designated cancer centers in LMICs. 

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Challinor JM, Galassi AL, Al-Ruzzieh MA, et al. Nursing’s potential to address the growing cancer burden in low- and middle-income countries. 

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Galassi A, Pradhan R, Palat G, LeBaron VT. Global oncology volunteering: making an effective contribution. 

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LeBaron VT, Palat G, Sinha S, et al. Recommendations to support nurses and improve the delivery of oncology and palliative care in India. 

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Cover Story

Volunteer nurses give their time and share their knowledge, empowering healthcare practitioners worldwide.

February 2020

Nurses Face Challenge of Closing Gap in Geriatric Care

Nurses, Set Goals in the New Year

Global Oncology Nursing Improves Cancer Care Worldwide