While cancer continues to be a leading cause of death globally, oncology nursing is constantly evolving and expanding to meet the emerging needs, including cancer prevention.

Why: It is estimated that 4 in 10 cancers are preventable.

 Tobacco and alcohol use, obesity, ultraviolet radiation, HPV, and a lack of physical activity may lead to cancer. Cancer survivors are more likely to experience ongoing quality-of-life issues and greater incidence of chronic disease.

 Oncology nurses interact daily with patients with cancer. Many of these people will become survivors and join the fast-growing group of individuals with a lack of precedent, necessitating evidence-based prevention and research aimed at prevention of recurrence and secondary malignancies. Nurses also meet with patients’ families who are undiagnosed with a malignancy, but are aware of risk factors and are willing to modify their behaviors. This group will have experienced the fear and threat to health vicariously.

The timing of the discussion and continued teaching must be conducive to learning. At diagnosis, the individual and family are overwhelmed by prognosis, a fear of underlying mortality, and head-spinning treatment plan details. Active treatment has been identified as the time when patients are most receptive.

Follow-up visits after treatment also provide a fantastic opportunity for reiteration about cancer prevention.

Patients may not approach oncology nurses for guidance on prevention. Nurses must be mindful of this and broach the topic. Medical oncology clinics, infusion centers, survivorship clinics, genetic counseling centers, and community cancer clinics are all excellent choices for prevention, screening, and teaching.

 A community outreach center with an active social media presence can be key to helping promote a healthy lifestyle. An interdisciplinary approach that includes primary care providers and resources for tobacco cessation, diabetes education, and obesity prevention is crucial. Dietary concerns can skyrocket during the treatment. To quell their concerns, an ADA-recommended diet can be initiated during active treatment and maintained even after completion. Where available, referrals to fitness and wellness centers are appropriate.

There is no universal solution to prevent cancer. Results are dependent on a variety of factors, but the goal is to raise awareness and recommend lifestyle modifications that are reliable, evidence-based, and sustainable. The necessary follow-up and reinforcement will

continue to be a challenge as we develop new strategies specific to individuals from all walks of life.

1. Cowens-Alvarado R, Sharpe K, Pratt-Chapman M, et al. Advancing survivorship care through the National Cancer Survivorship Resource Center: developing American Cancer Society guidelines for primary care providers. 

 2013;63(3):147-150. doi:10.3322/caac.2118

2. Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. 

. 2005;23(24):5814-5830. doi:10.1200/JCO.2005.01.230

3. Karvinen K, Bruner B, Truant T. The teachable moment after cancer diagnosis: perceptions from oncology nurses. 

 2015;42(6):602-609 doi: 10.1188/15.ONF.602-609

Articles

Partner Perspectives

Oncology nurses play a crucial role in cancer prevention.

Cancer Prevention: Why, Who, When, Where, How

The coronavirus disease 2019 (COVID-19) pandemic took what was mostly niche telehealth technology and brought it to a much larger patient population. But as the novelty has worn off and people have regained confidence in going to in-person appointments, both the government and private payers have begun making moves that will impact the technology’s long-term viability.

®, spoke with Thomas Conroy, CEO of MedSign, about how telehealth is viewed and what its future might look like.

: With the massive expansion of telehealth during the pandemic, how well has it worked out for clinicians and patients?

: In the beginning, telehealth was positioned for rural areas and now it’s across the nation. I think it’s a learning process. Because of COVID-19 and the inability to get the physician’s office, telehealth has opened up the door, but we have got to do a lot more than that. We need to make some technology changes to enable those who are, let’s say, technology averse, to access telehealth, in the comfort of their home, and I’m talking about seniors.

So I think overall, for [clinicians], you’ll find that the younger [clinicians] are totally open-minded and want to embrace telehealth and maybe the older doctors are the type that would like to see the patient in the home. And they’re going to learn over time that this is an incredible tool that they’ll have in their war chest to help to keep people healthy and well in the home.

Medical Economics®: In the past, Medicare primarily focused telehealth benefits on rural areas where care could often be hard to access. Is that the right approach?

 CMS took what they were doing in the rural areas and applied it to a nationwide program. It was a great way to start, and they understood some of the shortfalls there. What we need to do though…is make sure that the information that’s provided and the connectivity that is provided is for all Americans, and not just the young people today. They all understand just having happiness in your hand in the form of a cell phone is the way to go, because that’s what they live by. We’re going to see more and more of that as we progress in the telehealth arena. But we have to embrace those people and get others to adopt the system, and I think CMS has done that in the beginning here very well.

®: Many patients who used telehealth have since returned to in-office visits, and doctors who reported a lot of telehealth usage in early 2020 now say it’s declined. What does that say about the long-term future for telehealth?

 I think this is a generation issue. The old generation wants to be able to go into the doctor’s office, look them in the whites of their eyes, and get the people to care for them personally. The young people [are] used to the use of technology that exists today, and it’s just only going to grow. We’re not really seeing a real reduction, but an increase in in-home and in-office care. What we are seeing is that the seniors would like to actually talk and see the doctors themselves. Well, that will change over time as telehealth becomes commonplace.

And what you really have to consider is, there’s another area of seniors that is really important: those who have chronic diseases. They don’t want to go to the hospitals, they don’t want to see their doctors, they want to sit and stay in the comfort of their home, but you have to provide technology that enables them to do that.

There’s technology out there, like the one that I’m working on, that enables the seniors to talk to the physician or their nurse, or even their loved one, through the comfort of their home using a home television set. And I think that if we can apply that common technology that is in 120 million homes, we get to sell a winner here. 

When we talk about the seniors, you have to provide them what they know best, and that’s access to a product that they use every day in their home, and it’s a television set. So that will be the embracement part. The adoption part that telehealth needs is that you have to bring in those people who are pretty much using most of the Medicare and Medicaid dollars. It’s the seniors over 75 years of age especially. And here’s the other thing: That population is growing. Think about it: Because of all the health care that they’re receiving, they are living longer. We have to make sure that we can embrace those folks, and the way you do it is providing technology so that they can adopt it with ease.

Medical Economics

The pandemic brought telehealth into the mainstream, but will it stay there after the COVID-19 pandemic is over, especially as the population ages?

Telehealth: Hope or Hype?

The World Health Organization estimates that 30% to 50% of cancer cases are preventable, and usually people think this means modifying health behaviors such as not smoking tobacco, maintaining a healthy body weight, getting regular physical activity, limiting alcohol, and eating a healthily.

But there are additional ways to prevent cancer, including risk-reducing surgical procedures, screening, and early detection that remove precancerous lesions before they develop into cancer, or medical interventions such as chemoprevention.

As an oncology nurse working with people who have been diagnosed with cancer, you might not feel that cancer prevention is part of your practice. After all, you might be hanging their chemotherapy, managing their adverse events from radiation therapy, or helping them prepare for their surgical resection. But an oncology nurse can play an incredibly important role in cancer prevention as the patient moves across the cancer continuum.

For example, a woman I worked with as a breast oncology nurse navigator was newly diagnosed and developing a surgical plan for a lumpectomy. She confided that she didn’t understand why this was happening to her since no women had ever been diagnosed with cancer in her family. She had recently learned a few males in her family had been diagnosed with metastatic prostate cancer but hadn’t thought to share this with the oncology team. As an oncology nurse, I understood that metastatic prostate cancer is part of the National Comprehensive Cancer Network criteria for genetic testing,

 and I coordinated with her health care provider a referral for genetic counseling. Her genetic testing came back positive for the BRCA2 pathogenic variant and she felt very overwhelmed when her surgical oncologist recommended bilateral mastectomies.

We discussed the importance of preventing breast cancer in the contralateral breast and connected her to social support services. She did decide to have the bilateral mastectomies.

Later when she was completing her treatment and entering the survivorship phase, we discussed her health care provider’s recommendation for a risk-reducing salpingo-oophorectomy since she had an increased risk of ovarian cancer with the BRCA2 pathogenic variant. In the survivorship care plan, we discussed how colonoscopy and the Pap test are cancer screening tests that can remove precancerous lesions before they develop into cancer.

We also addressed cancer prevention for her family members by coordinating appointments for them with the genetic counselor.

Oncology nurses can talk to their patients about cancer prevention in the treatment phase as well as the survivorship phase. As trusted members of the health team, nurses are in a unique role to educate patients and their family members on cancer prevention and risk reduction strategies.

 World Health Organization. Accessed December 22, 2020. 

https://www.who.int/activities/preventing-cancer

2. National Cancer Institute. Cancer prevention overview (PDQ)-Health professional version. October 7, 2020. Accessed December 20, 2020. 

https://www.cancer.gov/about-cancer/causes-prevention/hp-prevention-overview-pd

3. National Comprehensive Cancer Network. Genetic/familial high-risk assessment: Breast, ovarian, and pancreatic (version 2.2021)

https://www.nccn.org/professionals/physician_gls/pdf/genetics_bop.pdf

4. Cancer screening tests. National Cancer Institute. January 16, 2019. Accessed December 26, 2020. https://www.cancer.gov/about-cancer/screening/screening-tests

Oncology nurses can play a key role in the prevention of certain cancers.

Oncology Nurses Can Help Prevent the Preventable

Since the start of the pandemic, more than 93.3 million individuals have contracted and died from the coronavirus disease 2019 (COVID-19).

 Measures such as the implementation of mandatory protective equipment, temporary closure of nonessential businesses, stay-at-home orders, and social distancing have been an asset in controlling the spread of the virus worldwide. Vaccine approvals have continued to reduce the incidence and prevalence of COVID-19.

The challenges that currently ravage the oncology community include the fear of contracting COVID-19, given that many patients with cancer already have a compromised immune system. Research says patients with cancer are twice as likely to die from COVID-19 and have worse outcomes compared with a patient who develops COVID without cancer.

 Given the complexity among the different types of cancer and their treatments, the cause of death also varies. It is known, however, that patients with hematologic malignancies are at higher risk for mortality given their lack of effective function among the cell lineage responsible for fighting this illness.

So is it safe for patients with cancer to receive the COVID-19 vaccine? First and foremost, patients should consult their primary oncologist before receiving the vaccine. Minority patients have a higher incidence of developing COVID-19 and should therefore be stratified appropriately for prioritization of the vaccine. Patients who are immunocompromised may receive the vaccine as long as there are no contraindications.3 Providers should tell these individuals that there are still unknowns regarding the vaccine’s impact on patients with compromised immune systems.3 Antibody testing should not be done to evaluate the effectiveness of the vaccine. It is also not recommended that patients be revaccinated after completion of chemotherapy or immunosuppressant therapy.

Ultimately, the FDA approval of COVID-19 vaccines offers a light at the end of the tunnel. However, nurses must be sure to discuss the vaccine with their patients to ensure that they are getting it at the safest time and in the safest manner possible.

1. World Health Organization. Coronavirus dashboard. Accessed Jan. 18, 2021. 

2. Foster V. Experts call for people with cancer to receive priority access to COVID-19 vaccines. Forbes. Accessed Jan. 18, 2021

https://www.forbes.com/sites/victoriaforster/2020/12/22/experts-call-for-people-with-cancer-to-receive-priority-access-to-covid-19-vaccines/?sh=55274ab57faa

3. Center for Disease Control and Prevention. Vaccines and immunizations. Accessed Jan. 17, 2021 

https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html

Nurse's Notes

The approval of COVID-19 vaccines has been celebrated worldwide. However, there is critical information that patients need before getting the shot.

COVID-19 Vaccine and Cancer: What Patients Ought to Know

The National Cancer Institute estimated that in 2020, 89,500 adolescent and young adult (AYA) patients (aged 15 to 39 years) would be diagnosed with cancer.

Receiving a cancer diagnosis at any age is troubling, but for the AYA population, the impact of cancer differs from that of pediatric and elderly patients. Oncology nurses can help meet the needs of their AYA patients by learning about their concerns and answering questions that may otherwise go unasked.

Donna Bell, MSN, RN, FNP-C, is a nurse practitioner at The University of Texas MD Anderson Cancer Center’s AYA program. The program, which was launched in 2019, provides a wide range of services designed specifically for adolescent and young adult patients with cancer. 

® spoke with Bell about the important role oncology nurses have when caring for the AYA patient.

“Cancer pulls AYA patients out of their peer groups and subsequently is very isolating,” Bell stated. “Expressing authentic compassion for what they are going through and asking meaningful questions makes it easier for them to talk about issues that matter. Nurses are well suited for these types of interactions.”

Bell offered some suggestions about the questions they might ask: “How are things going at work? What did you do this weekend? Who is your community? Are you having any sexual troubles?” AYAs often worry how cancer and cancer treatment will affect their independence, education, career, and fertility.

Questions related to these areas steer the conversation, guide interventions, and align appropriate referrals. Bell recommends that nurses be familiar with common concerns among AYA patients. “Employ a holistic approach. Look at the whole patient and not just the cancer treatment,” she said.

Patients may be concerned about the effects of cancer or cancer treatment on their ability to have children. Some may not have given the subject any consideration. Conversations about fertility and fertility preservation should be offered to all patients in this age group. These conversations are important and should address risk related to treatment and availability of options such as banking sperm or freezing oocytes.

Nurses can also be instrumental in helping AYA patients construct hope through goal setting, pathways thinking (routes for goal achievement), and overcoming barriers. A resiliency plan for meeting challenges can reduce anxiety and frustration. Hope-based interventions, virtual programming, and virtual support/activity groups have shown promise in improving quality of life, mental and physical health, coping skills, and pain tolerance.

Another area to address with AYA patients is educational/vocational planning. Referral to a vocational counselor can help patients plan their career trajectory around length of treatment, identify areas of flexibility, and perhaps recommend a change in course. “The disruptive nature of cancer can be an opportunity for growth,” Bell said. “Some young people are spurred to reevaluate their choices and in doing so, discover an interest they had not previously considered, such as a career in nursing or medicine.” The MD Anderson AYA Program website offers information and resources on these and other topics for patients and professionals.

By taking the time to understand the unique needs of the adolescent and young adult population, nurses can provide assurance to patients that their life matters, their needs matter, and they are not alone.

1. Cancer stat facts: Cancer among adolescents and young adults (AYAs) (Ages 15-39). National Cancer Institute. Accessed December 13, 2020. 

https://seer.cancer.gov/statfacts/html/aya.html

2. Nicoll I, Lockwood G, Chan RJ, Grundy P, Fitch MI. et al. What do adolescents and young adults perceive is the main challenge during the transition to survivorship? 

2020;30(4):309-313. Accessed December 13, 2020.

3. MD Anderson Cancer Center. Adolescent and Young Adult Program website. 

Adolescent and Young Adult Program | MD Anderson Cancer Center

Feature Story

Nurses can create an open dialogue for AYA patients to discuss cancer-related issues. 

Adolescent and Young Adult Patients Face Unique Needs, Challenges

Oncology nurses have an important role in the discussion of and education about complementary therapy, more commonly called integrative care.

“The word ‘integrative’ is key in the discussion,” said Eugenie Spiguel, MSN, ANP-BC, a nurse practitioner in the integrative medicine department at Memorial Sloan Kettering Cancer Center (MSK) in New York, New York. “When people look at the term ‘alternative,’ those therapies tend to be ones outside of the norms of cancer treatment—alternatives to standard of care. With integrative medicine, we are looking to complement standard of care.”

Education about the role of integrative medicine compared with alternative therapies is important, as more than 1 in 3 Americans believe that cancer can be cured solely through alternative therapies, according to the American Society of Clinical Oncology’s 2020 National Cancer Opinion Survey.1 Among women with breast cancer, only about half of patients disclosed use of complemen-tary and alternative medicines to their health care providers.2

Done successfully, integrative medicine can help manage a patient’s adverse events and enhance quality of life before, during, and after treatment into survivorship. “When you combine evidence-based treatments with the supportive services, that integrative approach to cancer care treats the disease with surgery, chemotherapy, and other conventional tools, [you're] supporting patients’ strength, stamina, and quality of life,” said Carolyn Lammersfeld, MBA, MS, RD, CSO, LD, vice president of integrative care services at Cancer Treatment Centers of America (CTCA).




Integrative care can include modalities as varied as behavioral health services, nutritional support, oncology rehabilitation, and pain management.

One example of integrative medicine used at MSK is acupuncture, according to Spiguel. Acupuncture involves the use of very thin needles along with heat, pressure, or electricity to stimulate points on the patient’s body.

“We have a robust acupuncture program and have used it to help patients deal with peripheral neuropathy associated with chemotherapy,” Spiguel said.

Researchers at MSK published a meta-analysis in 2012 that showed that acupuncture was an effective option for treating chronic pain.3 The center also has ongoing clinical trials to evaluate acupuncture in other areas, such as comparing it to massage for pain management in people with advanced cancer.4

“We also use acupuncture for hot flashes experienced by patients with breast, ovarian, or pros-tate cancer as a result of their treatment,” Spiguel said. “It can be used for joint pain caused by immunotherapy or other treatments and for the prevention of nausea and vomiting from chemotherapy.”

Spiguel also discussed treatments like meditation. “When we think about stress and anxiety from upcoming scans, or even while in an MRI machine, meditation can be helpful,” she said. “Patients can participate in classes and guided meditation.”

Clinicians may recommend integrative services as a complement to a patient’s initial treatment plan or at any point over the course of their treatment or survivorship, Lammersfeld said.

“For example, nutrition services may be used to complement antiemetics or antinausea medications to help reduce chemotherapy-induced nausea, making the treatment more tolerable and reducing treatment delays or interruptions,” Lammersfeld said. “Sexual health counseling may be offered to patients who have completed their cancer treatment and are now looking for a way to return their lives to normal.

”Another aspect of integrative medicine that should be discussed more with patients, Spiguel said, are physical activity and good sleep practices. During active treatment, studies have shown that regular physical activity can reduce fatigue, improve physical functioning, and have positive effects on self-esteem and quality of life.5-7

“When you consider that up to 80% of adults living with cancer are malnourished, and 1 in 2 patients has some form of nutritional deficit at the time of their diagnosis, nutritional support can be extremely important, too,” Lammersfeld said.

Alternatively, there are some things that oncology nurses should be on the lookout for that could cause harm to the patient. “We advise our patients to steer clear of any ‘therapy’ that is promoted as an alternative to evidence-based treatments like surgery, radiation, chemotherapy, and immunotherapy,” Lammersfeld said.

“For example, if a patient chooses to explore laetrile/shark cartilage, etc, instead of the chemotherapy recommended by their medical oncologist, they are not likely to change the trajectory of their cancer.”Patients should be cautioned against the use of vitamins, herbs, and supplements as a whole during active treatment. Supplements should be discussed with their provider or a medical professional with expertise in herbs and supplements and the effect on chemotherapy. Initiation of ServicesThese important services can be initiated by the patient or by the health care provider. “We have seen a lot of referrals from providers, whether they are advanced practice providers or physicians, as well asnurses who have seen good results with our services,” Spiguel said. “In other cases, the patients may have seen our services on the website."

Patients are pleasantly surprised, Lammersfeld said, when their health care providers offer supportive services as part of the treatment model.

Any conversation involving integrative medicine should be an open conversation, Spiguel said.

“You can’t just tell a patient no without discussing it; that shuts the patient down and they may end up taking things without discussing it with their providers,” Spiguel said. “Instead, open the conversation and explain things to your patient.

”For example, a nurse could explain that chemotherapy is metabolized by enzymes and herbs or supplements could interfere with that metabolism, causing side effects or making the treatment less effective.

The patient is at the heart of any treatment plan, so each conversation should take place on an individual basis, Lammersfeld said. “Create a safe environment for patients to share what they are doing or considering and allow them to ask questions,” she said. “Encourage their motivation to participate in their care by providing information on evidence-informed modalities, which may be helpful, while gently discouraging modalities which may be harmful or not safe during treatment.

”Nurses and patients looking to get more information about integrative medicine can look to the Society of Integrative Oncology (integrativeonc.org), which holds a conference each year, the American Holistic Nurses Association (ahna.org), which is not oncology specific but has great resources for integrative therapies, or the American Consortium of Integrative Medicine and Health (imconsortium.org), which has a nursing special interest group.

In addition, both MSKCC’s Integrative Medicine website and CTCA’s website contain great information for patients on the benefits of integrative care. “A lot of providers still view integrative or complementary medicine as a little bit outside of the realm of oncology, but a truly integrative approach can really provide benefits,” Spiguel said. “Every person who comes into contact with a patient can listen and dig deeper, especially if a patient is discussing problems they are having.”





1. National Cancer Opinion Survey, Harris Poll on behalf of the American Society of Clinical Oncology, 2020.
2. Wanchai A, Armer JM, Stewart BR. Complementary and alternative medicine use among women with breast cancer: a systematic review. 

2020; doi:10.1188/10.CJON.E45-55
3. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. 

 2012;172(19):1444-1453.
4. Memorial Sloan Kettering Cancer Center. A study comparing acupuncture with massage for pain and related symptoms in people with advanced cancer. Accessed December 8, 2020. 

https://www.mskcc.org/cancer-care/clinical-trials/19-341


5. Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O. Exercise interventions on health-related quality of life for people with cancer during active treatment. 

 2012(8):CD008465.
6. Courneya KS, Segal RJ, Gelmon K, et al. Six-month follow-up of patient-rated outcomes in a randomized controlled trial of exercise training during breast cancer chemotherapy. 

 2007(16):2572-2578.
7. Courneya KS, Sellar CM, Stevinson C, et al. Randomized controlled trial of the effects of aerobic exercise on physical functioning and quality of life in lymphoma patients. 

Cover Story

Integrative services offer modalities that can complement—not be used in place of—standard cancer treatments. 

February 2021

Cancer Prevention: Why, Who, When, Where, How

Telehealth: Hope or Hype?

Oncology Nurses Can Help Prevent the Preventable

COVID-19 Vaccine and Cancer: What Patients Ought to Know

Adolescent and Young Adult Patients Face Unique Needs, Challenges

Open Discussions Help Nurses Introduce Integrative Services