Oncology Nursing News® regrets to inform our readers that our beloved chairman and founder of MJH Life Sciences®, Michael J. Hennessy Sr, has passed away. Hennessy was a fierce supporter of oncology nurses and was devoted to improving the lives of patients with cancer. 

Hennessy spent his career turning his passion for building businesses and creating jobs into a run of successful ventures and brands. Following his graduation from Rider University in 1982, he started his career in medical publishing as a sales trainee, eventually advancing to the position of chief operating officer. In 1986, Hennessy became chief operating officer of Medical World Business Press, which was part of the launch of medical newspapers and other media products. The company prospered and was eventually sold to a Boston-based venture capital firm.

Hennessy launched Multimedia Healthcare Communications, LLC, in 1993 and built a portfolio of award-winning clinical journals. In 2001, Freedom Communications, Inc, acquired Multimedia Healthcare, about the time that Hennessy was pioneering a new approach to print and digital publishing with Intellisphere®, LLC (now part of MJH Life Sciences®). Guided by the principles of innovation and entrepreneurial spirit and reflecting its founder’s dedication to improving quality of life through health care research and education, Intellisphere® publishes a variety of integrated print and digital products focusing on a range of topics in research and clinical medicine. 

Hennessy’s commitment to improving the lives of patients with cancer is deeply rooted within the halls of MJH Life Sciences®. As a complement to the industry-leading OncLive® platform, he developed the Giants of Cancer Care® awards to recognize the leaders and pioneers who often go unrecognized for their contributions to advancing oncology care. He further strengthened his commitment to education by acquiring CURE Media Group in 2014, followed by the purchase of the Chemotherapy Foundation Symposium, in his quest to provide oncology professionals with focused education on innovative cancer therapy.

Later, in 2019, Hennessy elevated his role to chairman while naming his son Mike Hennessy Jr to assume the leadership role of the organization and carry on the family legacy. Under Mike Jr’s leadership, the company enhanced its global potential by entering into a long-term partnership with BDT Capital Partners, LLC, in November 2021.

Because of his broad business and educational experience and understanding of the challenges facing New Jersey, Hennessy’s counsel and insight had been sought out by several organizations including Rider University, where he served on the Board of Trustees and was elected to the executive committee. In addition to being active in state and national politics, Hennessy also had a long record of service at the local level, where he was a strong advocate for veterans and environmental issues.

Hennessy’s true passion was his relationship with his wife, Patrice “Patti” Hennessy. After meeting her in college, Hennessy devoted his life to Patti and his family, raising 4 wonderful children, Shannon, Ashley, Mike Jr, and Chris. Hennessy was Patti’s rock as she bravely battled cancer for almost 10 years until her death in January 2020. Hennessy recently honored Patti by making a donation to Rider University to expand the Science and Technology Center at their alma mater. The Mike and Patti Hennessy Science and Technology Center is set to be completed in 2022.

Hennessy’s legacy and “family first” mantra will live on through his children; their spouses Matt, Phil, Rachel, and Jordan, and his 10 grandchildren. He will be greatly missed by his family, friends, and MJH Life Sciences® family.

Articles

Hennessy spent his career turning his passion for building businesses and creating jobs into a run of successful ventures and brands.

Remembering Michael J. Hennessy Sr

If there is one thing that we are hoping to see in 2022, it is respite for the oncology nurse.

The COVID-19 pandemic has lasted longer than most of us predicted, and extra demands and strain have been placed upon the shoulders of all those who work in health care—particularly nurses. This issue’s Nurse’s Notes addresses the importance of taking personal time and resting to build resilience in everyday life. Our cover story looks ahead to the post–COVID-19 world and examines lasting practice changes, the endurance of telemedicine, adjusted visitor regulations, and more. 

Similarly, in this issue, we showcase various methods of eliminating burnout. Flip over to our Medical Economics® column to read up on how a novel device can help clinicians combat mental and spiritual fatigue. 

As always, our Medical World News® section keeps you up-to-date on practice-changing approvals in oncology. Follow our coverage of the 2021 accelerated approvals of asciminib (Scemblix), for the treatment of adult patients with Philadelphia chromosome–positive chronic myeloid leukemia in chronic phase, and tisotumab vedotin-tftv (Tivdak), for adult patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy. 

In addition, our Clinical Insights column provides key updates from the most anticipated oncology conferences held toward the end of 2021, including the American Society of Hematology Annual Meeting and Exposition and the San Antonio Breast Cancer Symposium. Chimeric antigen receptor T-cell therapies continue to revolutionize the realm of hematologic malignancies, and there is potential power with oral selective estrogen receptor degraders to eliminate the need for intramuscular injections in breast cancer. Updates with both treatments can be found in this section. 

The value of nurses cannot be overemphasized, and our feature story discusses how they can be at the forefront of electronic smoking cessation among young people. Moreover, our Adverse Events Report provides a primer on cannabis in the oncology space, as patients may feel more comfortable speaking to their nurse than their oncologist about their interests or concerns regarding medical cannabis. Lastly, our Advanced Practice Providers Page features a conversation about helping patients undergoing treatment manage cancer-related fatigue, and 

 podcast highlights how the implantation of phone triage programs can help improve wait times and make care more accessible to patients. Don’t forget to scan the QR code to listen to the full episode online. 

As demonstrated by literature, palliative care can greatly improve patient outcomes. Our Partner Perspectives offers input on the value of the oncology nurse in increasing palliative care referrals at the most effective time in a patient’s treatment. 

As we move forward, we want to thank oncology nurses everywhere for their dedication and service. We implore you to make this year one that is focused on healing and recovery and know that we are there with you every step of the way. 

From the Chairman

The COVID-19 pandemic has lasted longer than most of us predicted, and extra demands and strain have been placed upon the shoulders of all those who work in health care—particularly nurses

A Call for Resilience and Rest for the Oncology Nurse

In 2018, the US surgeon general issued an advisory calling for immediate action against the epidemic of youth electronic e-Cigarette use.

For the past 7 years, e-cigarettes have been the most commonly used tobacco product among US youth

 with an estimated 1 in 5 high school students and 1 in 20 middle school students using them.

Nurses are on the front lines and are a direct touch point in the effort to curb e-cigarette use among children and teenagers, according to Joelle Fathi, DNP, RN, ARNP, CTTS, FAAN, chief healthcare delivery officer at the GO2 Foundation for Lung Cancer and deputy chair of the Tobacco Control and Smoking Cessation Committee at the International Association for the Study of Lung Cancer. 

“Nurses [belong to] the No. 1 most trusted profession. If more nurses understand how these products hijack the brain and neurohormones, they can use this information to educate children and have [repeated] conversations about the harms before they are ever exposed,” Fathi said. 

Conventional or combustible tobacco includes tobacco products designed to be burned and smoked, such as cigars or cigarettes. In contrast, e-cigarettes work by heating the tobacco product. 

The FDA defines these products as electronic nicotine delivery systems (ENDS), which include vapes, vaporizers, vape pens, hookah pens, e-cigarettes, and e-pipes.

To best educate their patients, it is important that all nurses understand the mechanism of addiction for nicotine. 

“When someone inhales vapors from ENDS, those gases go into the depths of the lungs; they permeate across the very fine lining of the lung and into the arterial bloodstream,” Fathi noted. “From the time of inhalation it takes only about 7 seconds for any substance in that tobacco to reach the brain and other organs via the arterial blood stream. 

“There are other things that cause these surges, but nothing can touch the surge that nicotine causes. It takes only as few as 3 repetitive exposures to develop nicotine dependence,” she said. “When people use nicotine, even for a short duration, their neurocircuitry never goes back to normal.”

The good news, according to Mary Rezk-Hanna, PhD, NP, FAHA, an assistant professor at UCLA School of Nursing, is that there has been a clear reduction in the use of combustible cigarettes among adolescents. Unfortunately, the use of e-cigarettes and other alternative tobacco and nicotine products is offsetting that decline. Data show that from 2011 to 2018, the use of e-cigarettes increased among high school students from 1.5% in 2011 to 20.8% in 2018.

Nurses can raise awareness among adolescents about the amount of nicotine in e-cigarettes. For example, 1 combustible cigarette contains about 1 mg of nicotine. Smoking a pack of 20 cigarettes a day would equal 20 mg of nicotine. In comparison, one 3% JUULpod contains 35 mg of nicotine per mL, or about 23 mg of total nicotine at the time of manufacture. The 5% JUULpod contains 40 mg of nicotine.

e-Cigarettes have not been around long enough to fully understand the long-term associated health risks. However, as of 2020, more than 2800 hospitalized cases or deaths from e-cigarette or vaping product use– associated lung injury (EVALI) had been reported to the Centers for Disease Control and Prevention (CDC).

 Symptoms of EVALI include respiratory symptoms, gastrointestinal symptoms, and constitutional symptoms such as fever, chills, and weight loss. 

“Nurses have a critical role in controlling the smoking epidemic,” Rezk-Hanna said. 

Research findings have indicated that compared with smokers who receive usual care, smokers who receive assistance from a nurse have a 29% greater probability of successfully quitting for 5 or more months. This emphasizes the importance of nurses in efforts to curb tobacco use.

According to Rezk-Hanna, the 5 A’s framework for promoting smoking cessation (ask, advise, assess, assist, and arrange) is highly effective and nurses should be encouraged to use it with their patients. This means that nurses should identify tobacco use status for every patient at every visit (ask). They should urge tobacco cessation (advise) and determine whether the user is willing to attempt to quit (assess). For those who are willing, nurses should provide counseling and pharmacotherapy to help (assist), and schedule a follow-up (arrange).

“Assisting patients to achieve permanent [smoking] cessation is one of the most important services we can offer them to protect their health now and in the future,” Rezk-Hanna said. 

Some excellent cessation resources are available, including 1-800-QUIT-NOW, a national portal to a network of state quit lines. The Truth Initiative has launched an e-cigarette quit program to address the increase in youth vaping. To access the new program, users must text “DITCHJUUL” to 88709 to enroll. The American Lung Association’s Not On Tobacco is a voluntary quit program for young people aged 14 to 19. 

Treatment combined with behavioral counseling is the best way to help patients quit, Fathi said. Nurses have to be familiar with and know how to access local behavioral counseling resources and pharmaceutical treatments. For example, Yale Tobacco Center of Regulatory Science has launched a vaping cessation program for young people aged 14 to 19 years in Connecticut. 

“The biggest bang for our buck will always be to prevent youth from ever picking these products up,” Fathi said. “There is clear science that demonstrates that 90% of people who have used tobacco lifelong started before the age of 18.” “If we can change that…smoking will be obliterated.” 

1. Surgeon General’s advisory on e-cigarette use among youth. CDC. December 2018. Updated October 21, 2021. Accessed January 4, 2022. 

2. E-cigarette use among youth and young adults: a report of the Surgeon General. US Department of Health and Human Services. 2016. Accessed January 4, 2022. 

3. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: increase in use of electronic cigarettes and any tobacco product among middle and high school students – United States, 2011-2018. 

. 2018;67(45):1276-1277. doi:10.15585/mmwr.mm6745a5

4. Vaporizers, e-cigarettes, and other electronic nicotine delivery systems (ENDS). US Food and Drug Administration. Updated September 17, 2020. Accessed January 6, 2022. 

5. What is the size of a JUULPOD? JUUL. June 15, 2020. Accessed January 6, 2022. 

6. Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. CDC. Updated August 3, 2021. Accessed January 6, 2022. 

7. Rice VH, Hartmann-Boyce J, Stead LF. Nursing interventions for smoking cessation. 

 2013;(8):CD001188. doi:10.1002/14651858.CD001188.pub4

8. Five major steps to intervention (the “5 A’s”). Agency for Healthcare Research and Quality. December 2012. Accessed January 6, 2022. 

Feature Story

Awareness of the e-cigarette epidemic among youth could help
drive primary prevention.

The Rise of e-Cigarettes— What Nurses Should Know

Findings from an American Medical Association (AMA) national survey of nearly 21,000 health care professionals show that nearly half (49%) reported at least 1 symptom of burnout, and 43% said they suffered from work overload.

The costs of clinician burnout are steep; a 2019 study estimated that physician burnout costs the US health care industry $4.6 billion annually, mostly through clinician turnover and a reduction of clinical hours.

Subsequently, there are personal and professional costs. Clinicians with burnout may exhibit multiple symptoms, including low energy, exhaustion, compassion fatigue, insomnia, irritability, alcohol and drug abuse, and a lack of purpose in their jobs.

 Clinician burnout also can affect quality of care because physicians under physical and emotional duress are more prone to making mistakes, leading to poorer outcomes and increasing the risk of malpractice exposure. 

The time crunch resulting from high patient demand for services and a severe shortage of clinical professionals is also of concern, neither of which shows signs of abating soon. Data from a study from the early 2000s showed that the average patient visit with a primary care clinician lasted just over 15 minutes and often covered up to a half-dozen health issues.

 Worse, clinicians may spend large chunks of that valuable time attempting to find or enter data on a digital screen. 

Today, clinicians are trying to implement new models of digital care delivery during a once-in-a-century pandemic. Clinicians and care managers are overburdened with data, alert fatigue, and Best Practice Advisories that, in an effort to streamline care management, only make their work more difficult. Often they lack the basic clinical supplies and resources necessary to safely do their jobs. Furthermore, the trauma of working through the fear surrounding COVID-19 leaves little wonder as to why nurses are leaving their careers and years of training at alarming rates as they respond to mentally and physically draining shifts and unsafe patient loads. 

To add to the disruption, other clinicians are quitting their jobs in opposition to vaccine mandates by their states or employers. Health care organizations are struggling with chronic staffing shortages that limit how many patients can be seen and the quality of care that can be delivered. Ironically, staffing shortages can lead to increased spending because a hospital or health system might hire nurses on a contract basis at a higher rate than they would pay a full-time nurse. 

On the patient side, staffing shortages will inevitably affect not only the quality of care they receive, but whether they receive care at all. This is particularly so for patients with debilitating but not fatal conditions, such as deteriorating joints or other conditions requiring elective procedures. Care will always be provided for the most urgent cases, such as patients in an intensive care unit (ICU), but a woman who needs a knee replacement may not be able to schedule her procedure because clinicians are being redeployed to higher-priority patients. These are both medical and quality-of-life issues, the latter yet another cost of clinician burnout and staffing shortages. 

There is no magic bullet for reducing clinician burnout; rather, targeted solutions can be applied to each of the major causes. On the most basic level, giving clinicians the supplies and resources they need to effectively (and safely) provide care helps them to better manage the stress of their jobs. Health care organizations should communicate with clinicians to determine where there are supply and resource shortages and take steps to eliminate them. A review of the supply chain and inventory supply could also result in opportunities for cost savings. 

Reasonable patient loads would also go a long way toward easing clinician burnout. However, given the demand for care, shortage of clinical staff, and ongoing impact of the pandemic, clinicians aren’t likely to see relief in the form of full staffing levels any time soon. 

Fortunately, the right technology can address this major cause of burnout by making it far easier for clinicians to access the right patient data before and during an encounter, during which every minute is valuable. A technology platform that streamlines and organizes data for clinicians at the point of care also helps provider organizations offset the burden of staff shortages by dramatically increasing efficiency. Additionally, a platform with analytics capabilities supports care coordination and ensures that clinicians can track the most at-risk patients and provide outreach support if necessary. This type of preventive approach can help health care organizations avoid unnecessary costs and improve patient outcomes. Analytics-based prevention is especially valuable in cases where patients may be nonadherent with medication. Identifying and proactively reaching out to those patients can help counter possible adverse health events and prevent future unnecessary costs. 

A fully integrated care management platform can enable care managers to coordinate care and easily access relevant, actionable, and organized patient data when it is needed, promoting fast, evidence-based action at the point of care. Although technology alone can’t solve clinician burnout, it can provide the means for organizations to provide better care while increasing efficiency and alleviating stress. A comprehensive approach employing technology solutions, better resource allocation, and direct feedback from clinicians will be key to easing burnout across the industry. 

Prasad K, McLoughlin C, Stillman M, et al. Prevalence and correlates of stress and burnout among US healthcare workers during the COVID-19 pandemic: a national cross-sectional survey study. 

. 2021;35:100879. doi:10.1016/j.eclinm.2021.100879

Blanding M. The economic cost of physician burnout. Harvard Business School. September 25, 2019. Accessed December 9, 2021. 

Drummond D. Physician burnout: its origin, symptoms, and five main causes. 

Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians getting shorter? 

. 2001;344(3):198-204. doi:10.1056/NEJM200101183440307

Medical Economics

Although technology alone can’t solve clinician burnout, it can provide the means for organizations to provide better care while increasing efficiency and alleviating stress.

Care Management Tools Can Mitigate Clinician Burnout

As of February 2022, 37 states along with the District of Columbia have legalized medical cannabis, and 19 states plus the District of Columbia have legalized adult-use cannabis.

Unsurprisingly, the use of cannabis in patients with cancer appears to be increasing as more and more states are adopting cannabis legislation, both for medical and adult use.

Moreover, in addition to increased cannabis legalization, there has been an explosion of cannabidiol and other non-impairing cannabinoids that hit the market—thanks to the 2018 Farm Bill, which descheduled hemp.

With nearly two-thirds of the states allowing for medical cannabis use and the legalization of hemp, accessing cannabinoids has become much easier, especially for patients with cancer, which is a qualifying condition in almost every state. The increased access to cannabinoids has led to patients’ curiosity. Many of these patients are seeking symptom relief with cannabis and are turning to their oncology care team for further guidance.

Yet, many oncology professionals have had little to no education on cannabis.

 in 2018, 70% of medical oncologists felt unequipped to make clinical cannabis recommendations, and 46% of oncologists are recommending cannabis for symptom relief even though they have had no formal training.

 Additionally, an estimated 20% to 40% of patients with cancer are consuming some form of cannabis either during or after treatment—and that number may be underreported in states where cannabis is not legal.

Uncertainty exists among the different types of cannabis and whether clinical evidence supports cannabis use in certain medical conditions. Research is limited due to the federal designation of cannabis as a Schedule I drug.

Despite this restriction, there is sufficient evidence in some areas to demonstrate that cannabinoids may have a therapeutic effect. In 2017, the National Academy of Sciences, Engineering, and Medicine released The Health Effects of Cannabis and Cannabinoids report, which followed a review of more than 10,000 peer-reviewed journals. The authors concluded the following

1. Conclusive evidence suggests that cannabis or cannabinoids are effective at treating chronic pain in adults with chemotherapy-induced nausea and vomiting.

2. Moderate evidence suggests that cannabis or cannabinoids are effective at improving short-term sleep disturbances, and limited evidence suggests effectiveness at improving appetite and decreasing weight loss. 

3. There is insufficient evidence to demonstrate whether cannabis or cannabinoids are effective or ineffective in treating patients with gliomas or cancer-associated anorexia-cachexia. 

Despite the comprehensive review of the literature, generalized anxiety disorder and chemotherapy-induced peripheral neuropathy were not addressed. However, the report highlighted the need for more clinical research to better understand the therapeutic effects of cannabinoids in certain diseases.

Even though limited data support the use of cannabis as a first-line treatment in cancer-related symptoms, many patients are using it to relieve anxiety, pain, nausea, vomiting, and insomnia. In a recent Cancer study, 42% of 612 patients with breast cancer reported using cannabis for symptom relief.5 Seventy-eight percent used it to help with pain, 70% for sleep, 57% for anxiety, and 46% for nausea and vomiting relief.

Data also found that 39% of participants discussed their cannabis use with their physicians and that when they did, it was initiated by the patient 76% of the time. Moreover, only 4% of respondents listed their physician as the most helpful source of information on cannabis, instead listing the internet (22%), family members (18%), and dispensary staff (12%) as a more helpful source of information. This trend is concerning, considering that the internet is not always an accurate or reliable source of information and that dispensary staff often have no medical background and little cannabis education.

Oncology professionals can start to address patient questions and concerns by educating themselves on the endocannabinoid system, cannabinoids, routes of administration, dosages, potential drug-drug interactions, adverse effects, and common cancer-related uses and considerations.

Unfortunately, this information is not widely taught in medical or nursing schools, and without standardized cannabis education, clinicians are self-selecting sources to decrease their knowledge gap. Foundational knowledge of key concepts can allow oncology professionals to better guide patients to safe and effective use.

Discovery of the first cannabinoid receptor in 1988 led to detection of the endocannabinoid system (ECS). The ECS, of which the main function is to maintain homeostasis, is a molecular signaling system that consists of 2 cannabinoid receptors (most commonly CB1 and CB2), ligands, and enzymes that normalize sleep, pain perception, memory, mood, and appetite. These receptors can be stimulated by human endogenous cannabinoids as well as plant-derived cannabinoids (phytocannabinoids) and synthetic cannabinoids.

CB1 and CB2 are known as G protein–coupled receptors, and CB1 receptors are found predominantly in the adrenal glands, heart, kidneys, prostate, pancreas, colon, liver, central and peripheral nervous systems, lungs, testes, and ovaries. Upon CB1 receptor activation, the CB1 receptors assist in relief from depression, anxiety and stress, pain and inflammation, neurodegenerative disorders, posttraumatic stress, and multiple sclerosis–related symptoms.

CB2 receptors are also detected in the brain and peripheral nervous systems. However, these are mostly contained in the peripheral immune cells. These receptors are found in the brainstem neurons, lungs, microglia, and uterus. Upon activation, CB2 receptors are known to reduce inflammation and treat mental health disorders and neurologic diseases such as Alzheimer, Parkinson, Huntington, and multiple sclerosis.

Cannabinoids are defined as chemical compounds, which can be plant-derived (phytocannabinoids), synthetic, or endogenous, with the ability to influence the cannabinoid receptors while promoting neurotransmitter release. D-9 tetrahydrocannabinol (THC) and cannabidiol (CBD) are the 2 most commonly known cannabinoids, the first of which is primarily responsible for the euphoric effects of cannabis. Behavior, consciousness, mood, and perception are all altered by Δ-9 THC, which binds to CB1 receptors in the brain and causes a change to the function of the binding cell. Studies have suggested efficacy when using Δ-9 THC to treat the following conditions

CBD is typically the second most abundant cannabinoid in cannabis. It is psychoactive but not in the same manner as THC. It can alter mood, perception, and decrease anxiety. Studies have suggested that CBD can also treat patients with the following conditions

THC and CBD can be found in the cannabis plant along with more than 100 other cannabinoids and can often be purchased through licensed dispensaries in legal states or through hemp retailers (online and in store). Phytocannabinoids are not standardized, and states can set their own limits on potency and testing. FDA pharmaceutical-grade THC is available via dronabinol, which is synthetic and has been approved as an antiemetic and appetite stimulant. Cannabidiol (Epidiolex) is a medication that is derived from the cannabis plant and approved by the FDA as an anticonvulsant. In states where cannabis is legal for medical or adult use, patients can explore cannabinoids for a variety of health conditions without FDA approval.

Cannabis products offer various routes of administration, including topical, transdermal, inhalation, sublingual, and ingestion. Understanding the onset and duration of action can be helpful in determining which route will effectively treat patient symptoms. Unfortunately, products’ availability to patients depends on an individual state’s cannabis laws, and many state cannabis programs severely limit the product and formulary options.

Topical administration can provide localized relief within 15 minutes and often has little to no adverse effects (AEs). Upon activation, CB1 receptors on the skin assist in redness and inflammation reduction linked with conditions such as atopic and contact dermatitis and psoriasis. Evidence also suggests that topical cannabis can reduce arthritis-related pain and inflammation. There is little risk involved with this administration method.

Transdermal cannabis products—which are most commonly patches—are intended to penetrate the skin and reach the bloodstream and can provide between 6 and 12 hours of relief while avoiding first-pass metabolism. Transdermal products may be the optimal administration choice in patients whom drug interactions or medication adherence is a concern.

Inhalation provides relief quickly by reaching the bloodstream within minutes; this method is also found to be the most predictable while having the most control. It also provides a benefit for those who are unable to ingest other forms of medications. Chronic use has been associated with bronchitis and airway inflammation, so the benefit must outweigh the risk. Additionally, most indications for inhalation are short term.

Ingesting cannabis is a go-to choice for patients who suffer from chronic pain, inflammation, nausea, and insomnia because it can provide more durable and dependable relief. However, it does have variability in onset of action and is dependent on a patient’s metabolism, genetics, gender, and food intake. Taking these factors into consideration, the onset of action can range from 30 minutes to 2 hours or more. That being said, the effects of ingesting cannabis can last for at least 5 hours. Because of this factor, patients can overconsume and experience AEs, such as tachycardia, paranoia, hypotension, vomiting, and hallucinations. AEs associated with cannabis use are often from ingestible products. The use of the “go low and slow” method can help avoid some unwanted AEs associated with cannabis overconsumption.

Although drug interactions with cannabis are rarely hazardous, there is still potential for interactions to occur, especially with ingested cannabinoids. When taken orally, cannabinoids are metabolized by the cytochrome P450 (CYP) family of enzymes. THC is often metabolized by the CYP2C9, CYP2C19, and CYP3A4 enzymes, which convert THC into 11-hydroxy-THC. CBD, however, is commonly metabolized by the CYP2C19 and CYP3A4 enzymes, which convert CBD into 7-hydroxy-cannabidiol.

 Because most medications are metabolized by CYP3A4, CBD and THC can inhibit or induce other medications metabolized through that same

enzyme. Warfarin, among other medications, can inhibit or induce THC and CBD, which increases or decreases cannabinoid plasma levels.

 Cannabis should be used with caution with other central nervous system depressants, including alcohol, since it can generate sedative effects.

Cannabis dosing remains one of the most challenging components of providing care. Very few clinical trials have established dosing protocols with cannabinoids for specific conditions. As it stands, most dosing protocols have been developed from realworld evidence rather than evidence-based trials. The go-low-and-slow method is most applicable with cannabis. Because cannabinoids can have biphasic effects, a low dose is often sufficient for symptom relief.

With cannabis accessibility on the rise, many patients with cancer will be seeking guidance on the safe and effective use for symptom management. As cannabis research evolves and the industry matures, oncology professionals can look to cannabinoids as a potential supportive medicine. With proper guidance, cannabis can have a high safety profile with adverse effects that are generally well tolerated when administered at low doses. Patients are using it. Therefore, oncology professionals must be ready to meet the needs of their patients.

State Medical Marijuana Laws. National Conference of State Legislatures. Updated February 3, 2022. Accessed February 4, 2022. https://www.ncsl.org/research/health/ state-medical-marijuana-laws.aspx

Braun IM, Wright A, Peteet J, et al. Medical oncologists’ beliefs, practices, and knowledge regarding marijuana used therapeutically: a nationally representative survey study. 

. 2018;36(19):1957-1962. doi:10.1200/JCO.2017.76.1221

Worster B, Handley N, Ashare R, Meghani SH. What do oncology providers need to know about cannabis use in patients with cancer? ASCO Daily News. September 2, 2021. Accessed October 25, 2021. https://dailynews.ascopubs.org/do/10.1200/ ADN.21.200700/full

Adverse Events Report

With nearly two-thirds of the states allowing for medical cannabis use and the legalization of hemp, accessing cannabinoids has become much easier— especially for patients with cancer.

Medical Cannabis 101: What Oncology Nurses Need to Know 

Immunotherapy May Represent New Standard of Care in Metastatic TNBC 

Pembrolizumab (Keytruda) plus chemotherapy demonstrated a statistically significant and clinically meaningful improvement in progression-free survival (PFS) and overall survival (OS) vs chemotherapy alone in patients with previously untreated, locally recurrent, inoperable, or metastatic triple-negative breast cancer (TNBC) with a PD-L1 combined positive score (CPS) of 10 or higher, 

according to updated data from the phase 3 KEYNOTE-355 trial 

Furthermore, a PD-L1 CPS of at least 10 was found to be a reasonable cutoff to define the population of patients expected to derive the most benefit from this regimen. Results showed that the combination of pembrolizumab and chemotherapy yielded a median OS of 23.0 months vs 16.1 months with chemotherapy alone in patients with a CPS of 10 or higher (HR, 0.73; 95% CI, 0.55- 0.95; P = .0093). The 18-month OS rates were 58.3% with pembrolizumab vs 44.7% with placebo or chemotherapy. 

Moreover, the median PFS elicited by the combination was 9.7 months vs 5.6 months in patients with a CPS of at least 10 (HR, 0.66; 95% CI, 0.50-0.88). The 12-month PFS rate was 39.1% with pembrolizumab and 23.0% with placebo or chemotherapy. 

“These results provide further support for pembrolizumab in combination with chemotherapy as the new standard-of-care treatment regimen for patients with locally recurrent, unresectable, or metastatic TNBC whose tumors express a PD-L1 CPS of 10 or more,” said lead study author Javier Cortés, MD, PhD, head of breast cancer and gynecological cancers at Hospital Universitario Ramón y Cajal in Madrid, Spain, in a presentation of the data.

Cortes J, Cescon DW, Rugo HS, et al. Final results of KEYNOTE-355: randomized, double-blind, phase 3 study of pembrolizumab + chemotherapy vs placebo + chemotherapy for previously untreated locally recurrent inoperable or metastatic triple-negative breast cancer. Abstract presented at: 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021; San Antonio, TX.

Do Oral SERDs Hold Potential to Change Outpatient Practices?

The selective estrogen receptor degrader (SERD) elacestrant (RAD1901) led to a 30% reduction in the risk of disease progression or death compared with standard of care (SOC) in patients with estrogen receptor (ER)–positive, HER2-negative metastatic breast cancer who previously received CDK4/6 inhibition, 

according to results from the EMERALD trial

Data from the phase 3 trial showed that the median progression-free survival (PFS) by independent review was 2.79 and 1.91 months with elacestrant and standard therapy, respectively, in the intentto-treat population (HR, 0.697; 95% CI, 0.552-0.880; P = .0018). Standard therapy included either fulvestrant (Faslodex) or an aromatase inhibitor. 

In a subgroup of patients with ESR1 mutations, elacestrant was linked with a median PFS of 3.78 months vs 1.87 months with standard therapy. This led to a 45% reduction in the risk of disease progression or death in this subgroup (HR, 0.546; 95% CI, 0.387-0.768; P = .0005). 

Elacestrant, an oral SERD that blocks ER in a dose-dependent manner, has previously shown clinical activity in postmenopausal women with ER-positive, HER2-negative metastatic breast cancer.

Notably, experts have expressed that continued positive trial outcomes with oral SERDs have the potential to change outpatient practice by eliminating the need for intramuscular fulvestrant injections.

“Because it is an oral agent, the [main] thing to consider is that it does cause nausea,” stated Aditya Bardia, MD, MPH, Dana-Farber Harvard Cancer Center, 

in an interview with Oncology Nursing News®

 “It can also cause upper GI [gastrointestinal] discomfort. So, those are important education pieces for patients. If a patient is having a lot of acidlike symptoms, then the use of a proton pump inhibitor or other anti-acid [antacid] medications would be very reasonable. If a patient really has severe nausea, then the use of antinausea medication would be reasonable. But overall, the drug is well tolerated.”

Bardia A. Elacestrant, an oral selective estrogen receptor degrader (SERD), vs investigator’s choice of endocrine monotherapy for ER+/HER2-advanced/metastatic breast cancer (mBC) following progression on prior endocrine and CDK4/6 inhibitor therapy: results of EMERALD phase 3 trial. Abstract presented at: 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021; San Antonio, TX.

Bihani T, Patel HK, Arit H, et al. Elacestrant (RAD1901), a selective estrogen receptor degrader (SERD), has antitumor activity in multiple ER+ breast cancer patient–derived xenograft models. 

. 2017;23(16):4793-4804. doi:10.1158/1078-0432.CCR-16-2561

Bardia A, Kaklamani V, Wilks S, et al. Phase I study of elacestrant (RAD1901), a novel selective estrogen receptor degrader, in ER-positive, HER2-negative advanced breast cancer. 

 2021;39(12):1360-1370. doi:10.1200/JCO.20.02272

Dr Tolaney on the safety profile of SAR439859 in ER+/HER2 metastatic breast cancer. OncLive®. December 10, 2020. Accessed December 22, 2021. 

https://www.onclive.com/view/dr-tolaney-on-the-safety-profile-of-sar439859-in-er-her2--metastatic-breast-cancer

Breast Cancer–Related Lymphedema Rate Is Higher in Black Women Than White Women

Data presented at the 2021 San Antonio Breast Cancer symposium revealed that in patients with breast cancer

 treated with axillary lymph node dissection (ALND) and radiotherapy there is a 3.5-fold increased incidence of lymphedema among Black women compared with non-Black women.

The results also indicated that Hispanic women have a 3-fold increased incidence of breast cancer–related lymphedema compared with White women. However, Andrea V. Barrio, MD, FACS, an associate attending physician in the Breast Service, Department of Surgery at Memorial Sloan Kettering Cancer Center in New York, New York, remarked that more data are needed to confirm this observation. 

“Notably, the number of Hispanic women in our study was small,” explained Barrio, lead study author, in a presentation of the data during a press briefing ahead of the conference. 

At the beginning of her presentation, Barrio noted that results from epidemiological studies have shown that Black women with breast cancer have an increased susceptibility to developing lymphedema. However, as she discussed, there are very few prospective clinical trial data confirming those results. 

“The aim of our study was to assess the incidence of lymphedema in a prospective cohort of patients treated with ALND to identify risk factors associated with lymphedema development and to evaluate the impact of race and ethnicity on lymphedema incidence and severity,” she said. 

To evaluate this incidence, Barrio and her colleagues enrolled 827 women age 18 years and older with breast cancer in the trial. Patients also had to have received a unilateral ALND either in the primary setting or after a sentinel lymph node biopsy to be eligible for inclusion in the analysis. 

At a median follow-up of 22.6 months, 56 patients had developed lymphedema. The results demonstrated that the 12-month lymphedema rate was 8.8% (95% CI, 5.9%- 13%) and that the 24-month rate was 24.7% (95% CI, 19.2%-31.5%). The highest incidence of lymphedema observed was among Black women, with a 24-month lymphedema rate of 39.4%. That rate was 27.7% in Hispanic women, 23.4% in Asian women, and 20.5% in White women. 

The results also showed that receipt of neoadjuvant chemotherapy was associated with a higher 24-month lymphedema rate compared with up-front surgery at 30.9% vs 11.1% (P = .0066). Of note, among women with lymphedema, disease severity did not vary across racial and ethnic groups with similar relative volume changes observed. 

“We observed a higher incidence of lymphedema in Black women treated with ALND and radiotherapy after adjustment for other variables. Similar findings were observed in Hispanic women, but confirmation in a larger data set is needed,” Barrio concluded.

Barrio AV, et al. Impact of race and ethnicity on incidence and severity of breast cancer related lymphedema after axillary lymph node dissection: results of a prospective screening study. Abstract presented at: 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021; San Antonio, TX.

Clinical Insights

Combination therapy, selective estrogen receptor degraders, and more were covered at the 2021 San Antonio Breast Cancer Symposium.

SABCS 2021 Highlights & Conclusions

Acalabrutinib Provides Long-Term Survival Benefits vs Standard of Care in Relapsed/Refractory CLL 

Treatment with acalabrutinib (Calquence) for relapsed/refractory chronic lymphocytic leukemia was effective out to 3 years and demonstrated a progression-free survival (PFS) benefit over standard of care, 

according to a 3-year follow-up of the ASCEND study 

Long-term follow-up data from ASCEND, which were presented by Wojciech Jurczak, MD, PhD, head of the Department of Hematology at Maria Sklodowska-Curie National Research Institute of Oncology in Kraków, Poland, also demonstrated that acalabrutinib was well tolerated with no new safety findings. 

During follow-up, patients treated with acalabrutinib monotherapy had significantly prolonged PFS compared with those treated with idelalisib (Zydelig)/rituximab (Rituxan) or bendamustine (Bendeka)/rituximab (median, not reached [NR] vs 16.8 months; HR, 0.29; 95% CI, 0.21-0.41; P < .0001). More patients in the acalabrutinib group achieved 36-month PFS compared with those in the investigator–selected treatment group (63% vs 21%). When investigators assessed the groups separately, they observed similar benefits regarding PFS when comparing acalabrutinib with idelalisib/rituximab (median, 16.2 months; HR, 0.31; P < .0001) and with bendamustine/rituximab (median, 18.6 months; HR, 0.25; P < .0001). 

“Overall, these data support the use of acalabrutinib in patients with relapsed/ refractory chronic lymphocytic leukemia, including those with high-risk features,” Jurczak said during the presentation.

Jurczak W, Pluta A, Wach M, et al. Three-year follow-up of the ASCEND trial: acalabrutinib vs rituximab plus idelalisib or bendamustine in relapsed/refractory chronic lymphocytic leukemia. Presented at: 63rd American Society of Hematology Annual Meeting and Exposition; December 11-14, 2021; Atlanta, GA.

Ibrutinib Plus FCR Shows Encouraging Activity as Time-Limited Option for Younger Patients With CLL 

The addition of ibrutinib (Imbruvica) to fludarabine, cyclophosphamide, and rituximab (Rituxan; iFCR) resulted in a higher rate of complete responses (CRs) with bone marrow undetectable minimal residual disease (BM-uMRD) in younger, fit patients with chronic lymphocytic leukemia (CLL), 

according to long-term data from a phase 2 study 

Moreover, these results included patients with unmutated IGHV, a population who rarely has durable responses, according to Matthew S. Davids, MD, MMSc, director of clinical research in the Division of Lymphoma at Dana-Farber Cancer Institute and an associate professor of medicine at Harvard Medical School. 

“Other studies have suggested that patients treated with ibrutinib-based therapy have variable benefits, even with IGHV-unmutated disease. However, we have not seen larger data yet for the combination of ibrutinib with FCR,” said Davids during a presentation of the data. “We hypothesized that combining ibrutinib with FCR as initial therapy would lead to a high rate of CR with BM-uMRD in a broad population of younger, fit patients [with CLL].” 

The median number of ibrutinib maintenance cycles was 24 (range, 0-81). In the intent-to-treat (ITT) population, the rate of CR with BM-uMRD improved to 55% (n = 47) and the best rate of BM-uMRD remained at 84% (n = 71). The CR rate deepened with ibrutinib maintenance therapy, from 34% to 81% as the best rate. This was similar among the IGHV-mutated and -unmutated patients, up from 41% to 88% and up from 28% to 76%, respectively, as the best rates. Lastly, the BM MRD-negative rates in the ITT population were 91% in the 81 patients with the TP53 mutation. With the time-limited novel agent plus chemoimmunotherapy, 3-year progression-free and overall survival rates were 97% and 99%, respectively. Thirteen patients (21.3%) who discontinued ibrutinib have had recurrent BM-MRD, including 5 patients with clinical progression of CLL. Seven patients restarted treatment with ibrutinib, all of whom have experienced partial responses. The median time on retreatment is 12.8 months (range, 4.2-26.2).

Davids MS, Brander DM, Tyekucheva S, et al. Longer-term follow-up of a multicenter, phase 2 study of ibrutinib plus fludarabine, cyclophosphamide, rituximab (iFCR) as initial therapy for younger patients with chronic lymphocytic leukemia. Abstract presented at: 63rd American Society of Hematology Annual Meeting and Exposition; December 11-14, 2021; Atlanta, GA.

Cilta-Cel Continues to Impress With Durable and Deep Responses in Relapsed/Refractory

Ciltacabtagene autoleucel (cilta-cel) elicited a 97.9% objective response rate (ORR) and an 82.5% stringent complete response (sCR) rate in patients with relapsed/refractory multiple myeloma at a median of approximately 2 years of follow-up, 

from the phase 1b/2 CARTITUDE-1 trial (NCT03548207).

Additionally, the 2-year progression-free and overall survival (OS) rates were 60.5% and 74.0% in all patients, respectively, and minimal residual disease (MRD) negativity was achieved in 92% of evaluable patients for MRD (n = 61). The 2-year progression-free survival (PFS) rates were improved in those who had MRD negativity sustained for at least 6 and 12 months, at 91% and 100%, respectively, as well as the 2-year OS rates at 100% and 100%. 

“These data are encouraging, and they suggest that cilta-cel will be an important treatment option for patients with multiple myeloma,” said lead study author Thomas Martin, MD, a clinical professor of medicine in the Adult Leukemia and Bone Marrow Transplantation Program, and associate director of the Myeloma Program at the University of California, San Francisco, in a presentation on the data. 

Cilta-cel is a B-cell maturation antigen (BCMA)-directed chimeric antigen receptor (CAR) T-cell therapy with 2 BCMA-targeting single-domain antibodies that are designed to confer avidity. A biologics license application seeking approval for the agent is currently under priority review with the FDA for its use in adult patients with relapsed and/or refractory multiple myeloma. 

In November 2021, the FDA extended the Prescription Drug User Fee Act target date for the application to review recently submitted data linked with an updated analytical method following the agency’s request for information request that was issued by the agency.

 The new action date is February 28, 2022.

Martin T, Usmani SZ, Berdeja JG, et al. Updated results from CARTITUDE-1: phase 1b/2Study of ciltacabtagene autoleucel, a B-cell maturation antigen–directed chimeric antigen receptor T-cell therapy, in patients with relapsed/refractory multiple myeloma. Abstract presented at: 63rd American Society of Hematology Annual Meeting and Exposition; December 11-14, 2021; Atlanta, GA.

US Food and Drug Administration grants BCMA CAR-T cilta-cel priority review for the treatment for relapsed/refractory multiple myeloma. News release. Legend Biotech Corporation. May 26, 2021. Accessed December 13, 2021. 

Liso-Cel Outperforms Standard Therapy in Improving QoL in Relapsed/Refractory LBCL

Lisocabtagene maraleucel (liso-cel; Breyanzi) fostered a better quality of life (QOL) in patients with relapsed/refractory large B-cell lymphoma (LBCL) compared with current standard of care (SOC), 

according to data from a comparative analysis of the phase 3 TRANSFORM trial 

Evaluable patients who received the chimeric antigen receptor (CAR) T-cell therapy (n = 47) experienced a mean change in cognitive functioning of 2.21 (range, –1.48 to 5.90) vs –2.09 (range, –6.00 to 1.83) in those who received SOC (n = 43); this translated to a difference of 4.30 (range, –0.76 to 9.36) on day 126 from baseline. 

Those in the liso-cel arm also experienced a mean change in fatigue of –1.95 (range, –7.40 to 3.51) compared with 3.75 (range, –2.17 to 9.68) in the SOC arm, equating to a difference of –5.70 (range, –13.24 to 1.84) on day 126 from baseline. In these domains, the liso-cel group improved, whereas the SOC group deteriorated. 

The liso-cel group also experienced mean changes in physical functioning and pain of –2.75 (range, –6.76 to 1.25) and –11.14 (range, –16.37 to –5.92), respectively, compared with –2.17 (range, –6.64 to 2.30) and –15.56 (range, –21.25 to –9.88), respectively, for the SOC group. The differences between the 2 arms in physical functioning and pain were –0.58 (range, –6.17 to 5.01) and 4.42 (range, –2.72 to 11.56), respectively. 

“Overall QOL was either improved or maintained from baseline in patients with relapsed/refractory LBCL who received liso-cel as second-line treatment,” presenting study author Jeremy Abramson, MD, director, Jon and Jo Ann Hagler Center for Lymphoma, associate professor of medicine, Massachusetts General Hospital Cancer Center, said during a presentation of the data. “These findings corroborated with previously reported health-related QOL associated with liso-cel treatment.” 

Abramson J, Solomon S, Arnason J, et al. Improved quality of life (QOL) with lisocabtagene maraleucel (liso-cel), a CD19-directed chimeric antigen receptor (CAR) T cell therapy, compared with standard of care (SOC) as second-line (2L) treatment in patients (pts) with relapsed or refractory (R/R) large B-cell lymphoma (LBCL): results from the phase 3 TRANSFORM study. Poster presented at: 63rd American Society of Hematology Annual Meeting and Exposition; December 11-14, 2021; Atlanta, GA.

Oral Bruton tyrosine kinase inhibitors make notable strides in CLL treatment. Chimeric antigen receptor T-cell therapy continues to command attention by besting standard-of-care therapies. 

63rd American Society of Hematology Annual Meeting and Exposition: Major Nurse Takeaways 

Palliative care (PC) is fundamental to high-quality cancer care, particularly in the advanced setting. The incorporation of this specialty has been shown to improve quality of life (QOL),

 reduce physical and psychological burden, and improve overall survival in some cases of advanced cancer.

Notably, health care organizations such as the American Society of Clinical Oncology (ASCO), the Institute of Medicine, and the National Comprehensive Cancer Network all support the integration of PC into standard oncology care.

 However, despite its substantial value, PC continues to be underused throughout the country.

Our outpatient cancer center in Southwestern Pennsylvania is not immune to this trend. While the majority (>94%) of patients treated in our clinical trial unit in 2018 had distant metastasis, only 17.3% had a PC referral. These numbers are in sharp contrast to ASCO guidelines, which recommend that all patients with advanced disease be followed by specialized PC providers while receiving cancer treatment.

To combat this discrepancy, a nurse-driven PC referral intervention was evaluated in our outpatient clinical trial unit. This intervention included development and delivery of nurse and patient education, creation of an evidenced-based PC screening tool, and establishment of a formal procedure for nurse-led PC referrals. 

The procedure for nurse-driven PC referrals included all patients visiting the unit for oncologic treatment. Treatment nurses determined if the patient was already supported by a PC specialist. If a nurse identified a patient who was not receiving PC, they would consequently fill out the PC screening tool (Figure 1). Patients who screened positively on the tool received verbal and written PC education from the nurse, and if they demonstrated interest in PC, they were connected with the PC clinic located in the cancer center. 

Education for treatment nurses was delivered by the author during a 30-minute inservice on the nursing unit. The education focused on the purpose and benefits of PC; potential patient, clinician, and institutional barriers; strategies for effectively discussing the specialty; and introduction to the procedure for nurse-driven PC referrals. This information was provided verbally and reinforced with written materials. Reeducation and one-on-one coaching were periodically provided throughout the quality improvement study period. The education provided to the nursing staff served to improve the verbal education they provide to patients. Patient education was also improved through the distribution of a flyer discussing PC and highlighting resources available at the outpatient cancer center. 

A nurse-driven palliative care referral intervention demonstrated preliminary success in increasing the number of patients who received this form of supportive care. 

February 2022

Remembering Michael J. Hennessy Sr

A Call for Resilience and Rest for the Oncology Nurse

The Rise of e-Cigarettes— What Nurses Should Know

Care Management Tools Can Mitigate Clinician Burnout

Medical Cannabis 101: What Oncology Nurses Need to Know

SABCS 2021 Highlights & Conclusions

63rd American Society of Hematology Annual Meeting and Exposition: Major Nurse Takeaways

Power of Palliative Care: How Oncology Nurses Can Increase Referrals

The Face of Moral Distress and Self-Stewardship Among Oncology Nurses

Shifts in Oncology: Safely Treating Patients in a Post–COVID-19 World

Access-Focused Care: The 4-1-1 on Oncology Phone Triage Programs