	In early August 2004, 44-year-old John Saltanovitz began to experience difficulty breathing, which he attributed to a sinus infection or allergies. The symptoms persisted despite John’s use of over-the-counter sinus medications, and on August 31, after he and his wife, Leah, noticed that his left eye seemed to be protruding, he saw his family physician.

	The doctor put John on a course of antibiotics for what appeared to be a sinus infection but, concerned about the eye, scheduled magnetic resonance imaging (MRI) for September 16. The MRI revealed a mass in the sinonasal area described as “likely malignant” and, the next day, a biopsy was performed by an ear, nose, and throat specialist, who recommended that John see an oncologist immediately.

	On September 28, John was seen at a world-renowned cancer center, where he was diagnosed with undifferentiated sinonasal carcinoma (T-4B) with invasion into the brain and into the eye, causing cranial nerve damage and ophthalmic extrusion. The tumor was deemed nonresectable, and no curative options were offered.

	John decided to seek a second opinion and was seen at the University of Chicago Comprehensive Cancer Center (UCCCC) in early October. The diagnosis was confirmed with a repeat MRI and panendoscopy, and distant metastasis was ruled out with computed tomography (CT).

	On October 12, John began three cycles of outpatient induction chemotherapy with cisplatin and paclitaxel. He tolerated the treatment well, and post-treatment MRI showed that his tumor had become appreciably smaller.

	On November 28, a port was inserted and John began five cycles of chemotherapy (paclitaxel, 5-FU, hydroxyurea) with concomitant radiation, administered in a 5-days-on, 9-days-off regimen.

	John recalls feeling fine until he was being prepared for discharge after the first week of treatment, and needed to be readmitted through the emergency department with a fever and severe mucositis. He also had apparent 5-FU-related hand/foot syndrome, causing the skin to peel off his hands and feet, for which he was treated with topical creams and instructed to wear gloves and socks, which he changed three to four times daily. Because of the mucositis, a g-tube was inserted during this hospital stay, and remained in place until the end of April.

	Roughly 1 month after completion of John’s chemotherapy, a repeat MRI showed that a complete response had been achieved, and a subsequent biopsy confirmed that John had no evidence of cancer. Scans performed during 5 years of follow-up continued to show no evidence of cancer.

	John describes residual treatment-related effects as episodic nose bleeds, a diminished sense of smell, increased nasal drainage, and dryness in the nasal passages requiring once-daily rinses with moisturizing drops. He also reports blocked tear ducts and excess watering.

	Allison Dekker, BSN, RN, OCN®, began educating and preparing John for treatment during his initial visit to UCCCC. She explained that the most common adverse effects seen with the selected induction chemotherapy are nausea and vomiting, as well as nephrotoxicity. Patients are typically pre-medicated with the NK1 receptor antagonist Emend (Merck) to prevent nausea, are given IV fluids to flush the kidneys, and are instructed to keep well-hydrated throughout treatment, she said.

	The mucositis and dermatitis John experienced after radiation and chemotherapy are typical side effects of that regimen, Dekker added. “We first attempt to manage the mucositis symptoms with a grade I mouth wash used four times daily but, as in John’s case, a feeding tube often needs to be inserted,” she said. She added that, due to skin breakdown, “we need to be especially vigilant about keeping the neck area clean and dry, and often use a triple-antibiotic ointment and a Vigilon dressing to manage pain and help prevent infection.”

	Dekker noted that “head and neck cancers can adversely impact a patient’s ability to speak, eat, and even swallow,” so many patients are referred to a speech and swallowing specialist. Due to nausea from treatment, she added, patients are encouraged to eat a diet high in fat, calories, and protein between rounds, and typically meet with a nutritional specialist before therapy begins.

	The Second Opinion: The Importance of Self-Advocacy

	“John’s case illustrates the importance of a patient’s willingness and ability to be his own advocate,” said UCCCC physician Ezra Cohen, MD, noting that John’s decision to seek out a second opinion was what saved his life. Even so, patients (and even clinicians) often don’t know which facilities are considered leaders in the treatment of various types of cancer, Cohen said, and a bit of detective work is generally required.

Patients (and even clinicians) often don’t know which facilities are considered leaders in the treatment of various types of cancer, and a bit of detective work is generally required.

	Not surprisingly, John is grateful not only to his physicians and nurses, but also to his wife and other family members and friends, all of whom refused to let him give up his fight.

	Initially, he said, “we were at one of the best cancer centers in the world, but it was on the suggestion of one of the physicians in that center, and with my wife’s research and persistence, that we ended up at a facility that has pioneered many of the treatments used for my type of cancer.”

Laura Bruck is a freelance writer and editor based in Cleveland, Ohio. She has specialized in healthcare reporting since 1987.

Articles

Patient Focus

Patients (and even clinicians) often don't know which facilities are considered leaders in the treatment of various types of cancer, and a bit of detective work is generally required.

A Patient Is His Own Best Advocate

 Nurse staffing varies from institution to institution, depending on many factors, both internal and external. To gain a better understanding of nurse staffing, ratios of nurses to patients, and productivity, a survey was sent to ONS members. At the ONS 37th Annual Congress, responses to the survey pertinent to inpatient oncology settings were presented and discussed by Angela Adjetey-Appiah, RN, patient care director, New York-Presbyterian Hospital/Columbia University Medical Center, New York City. Due to the survey’s findings, she said, the ONS plans to add a section with staffing exemplars to its website.

	“The goal of staffing each oncology inpatient unit is to ensure patient safety in healthcare delivery,” Adjetey-Appiah explained. “Nurses are scheduled in sufficient numbers to provide quality and safe care. The staffing mix is a determinant of the safety of the work environment and the safety of patient care. Nurse recruitment and retention efforts are critical to retaining expert staff.”

	According to Adjetey-Appiah, the American Nurses Association’s principles for nurse staffing suggest that the following factors be identified:

		Intensity level of the care needed by patients

		Characteristics of the work environment, including architecture and available technology

		Experience and expertise of the nursing staff

	The support of a multidisciplinary staff is important, she added, as is a facility’s involvement, or lack thereof, in research at the basic-science or clinical level.

	Because patient needs are ever-changing, Adjetey-Appiah said, patient classification and acuity systems that are used to track and predict nurse staffing needs can be helpful, and easily understood by nurses when taught appropriately.

					The total number of oncology beds in inpatient hospitals ranged from 30 to 217.

					Overall, the average nurse-to-patient ratio was 1:5; with chemotherapy, the average ratio was 1:4 or 1:3.

					Patient populations at respondents’ institutions were as follows: 32% included medical oncology; 12.5% had non-oncology medical; 15.5% had surgical oncology; and 8% had non-oncology surgical.

					Twenty nine percent of respondents’ institutions utilized non-licensed staff; 6% did not; and 65% did not specify.

					Productivity measures were used to determine staffing in 26.5% of respondents’ institutions and were not used in 5.5%; 68% of respondents did not answer this question.

					Non-licensed personnel were included in the productivity measure, according to 24% of respondents, while 2.5 % of respondents said they were not included and 73.5% did not answer the question.

					When asked which productivity measures were used to set staffing, 18.5% used hours per patient day; 1% used hours per adjusted patient day; 0.5% used budgeted hours; 0.5% used budgeted productive hours; 5% used nurse/patient ratio; 1% used “other”; and 73.5% did not answer the question.

	“To determine how many patients one nurse can care for is a difficult question to answer due to the variety of settings in oncology inpatient units. Any nurse will tell you it all comes down to the individual patient and how much care he or she needs,” Adjetey-Appiah commented.

	Two hundred people responded to the ONS survey (

). Responses give a bird’s-eye view of staffing situations in various inpatient units; however, about two-thirds of respondents did not answer several questions.

	Based on the survey results and on staffing principles, some examples of staffing guidelines are as follows, with the same number of registered nurses (RNs) needed for either a day or a night shift:

	“The survey confirms why ONS opted not to have set guidelines on staffing,” Adjetey-Appiah said. “The diversity and variety of inpatient units are too complex to set one standard. However, the survey revealed a need to use exemplars as guidelines when staffing oncology units. Examples collected from different institutions will be posted on the ONS website.”

Conference Highlights

Nurse staffing varies from institution to
institution, depending on many factors, both
internal and external. To gain a better
understanding of nurse staffing, ratios of nurses to
patients, and productivity, a survey was sent to ONS
members.

Oncology Nurse Staffing Is Variable and Multifactorial

Although the role of adequate nutrition in cancer patients is gaining recognition as being important, the area is often neglected as a key component of nursing care, according to a speaker at the ONS 37th Annual Congress.

	Since about 50% of cancer patients have nutritional issues at diagnosis, and treatment can exacerbate weight loss and deteriorate nutritional status, it is vital for oncology nurses to ensure that malnutrition is diagnosed and treated, said Meghan Routt, MSN, RN, James Cancer Hospital, The Ohio State University Medical Center, Columbus. The issue should be given attention across the cancer care continuum, she said, since oncology patients can encounter nutritional challenges at any time from diagnosis through curative treatment or palliative care.

	In helping such patients, Routt added, nurses should be aware of several studies demonstrating that individualized nutrition counseling by a registered dietitian can help reverse weight loss/malnutrition and improve overall health and social functioning, functional status, and quality of life.

	“Every patient who walks through the door should be screened for malnutrition,” she advised. “Patients should be followed closely to be sure they are paying attention to nutrition. The patient is a partner in the process.”

	Nutritional complications from chemotherapy, surgery, radiotherapy, and immunotherapy are frequent, can be expensive to treat, and can limit therapy, Routt said. In particular, she said, malnutrition can impair wound healing and increase morbidity, mortality, muscle loss, the rate of infection and other complications, the likelihood of hospital admission, and the length of hospital stays.

	Among the side effects of cancer or its treatment that can affect nutritional status is cachexia (ie, ongoing loss of skeletal muscle mass), which cannot be fully reversed through conventional nutritional support. The diagnosis of cachexia should be suspected, Routt said, if a patient experiences weight loss in excess of 5% over 6 months or the body mass index (BMI) falls below 20 and the patient experiences more than a 2% weight loss over the same time period.

	Other common side effects—often related to treatment&mdash; that affect nutritional status include nausea, vomiting, anorexia, mucositis, esophagitis, fatigue, and diarrhea or constipation. About 50% of patients experience some degree of nausea and vomiting, Routt said, and this commonly affects nutritional intake.

	In a study of 191 cancer patients treated with chemotherapy, 49% were malnourished, 46% required symptom management and/or nutritional intervention, and 89% had five or more nutrition-related symptoms [

. 2010;62:220-228]. Surgery for cancer also is associated with nutritional problems. Malnourished surgical patients are at increased risk for postoperative morbidity and mortality, so weight loss should be taken seriously, Routt noted.

	Cancers that affect the digestive tract pose specific nutritional risks, she said. Surgery for head and neck cancer can create problems affecting the ability to speak, chew, salivate, swallow, smell, and taste. Enteral feeding tubes may be necessary. Treatments for gastrointestinal cancer can result in gastroparesis, alterations in digestion, malabsorption of nutrients, and a host of related digestive-tract abnormalities.

	Side effects of radiation can affect ingestion, digestion, and absorption of nutrients, Routt added. Diarrhea, nausea, vomiting, enteritis, and malabsorption are common gastrointestinal side effects of radiation. Side effects of immunotherapy can also compromise nutritional status.

	“Nutrition is an aspect of care where early recognition [of malnourishment] and intervention are vital,” Routt said. “This may be the only area of care where a patient can have a sense of control over his/her life. Instead of making nutrition a source of tension and anxiety, the cancer nurse can try to address patients’ needs by encouraging them to become involved in maintaining adequate nutritional status early in the treatment process, so that they become proactive about their nutritional needs.”

Although the role of adequate nutrition in cancer patients is gaining recognition as being important, the area is often neglected as a key component of nursing care.

Importance of Adequate Nutrition Emphasized

Genetic testing for breast and ovarian cancer receives a lot of attention from the media, clinicians, patients, and the general public. Perhaps less well known is that colon cancer is equally likely to be hereditary (approximately 10% of cases, overall) and that there are many different genes responsible for these cases. Even less well known is that mutations that cause hereditary colon cancer can also increase the risk of several other cancers and physical findings. Patients may not realize, for example, that a family history of uterine cancer is relevant to their personal history of colon cancer. The oncology nurse can play a pivotal role in helping to elicit this history from the patient and determining which cases require a referral for genetic counseling.

Which of My Patients Are at Increased Risk for Hereditary Colon Cancer?

	A personal history of early-onset colon cancer (<50 years), even in the absence of a family history, warrants a referral for genetic counseling. Similarly, a personal history of multiple polyposis warrants further investigation. Being aware of these and other risk factors (

) can help you determine when to make referrals for genetic counseling and testing.

	Many hospitals are now performing immunohistochemistry [IHC], as well as tests for microsatellite instability [MSI], on some, or all, colon and uterine cancers. These screening tests can help determine which of your patients are at increased risk for a hereditary cancer syndrome. Keep in mind that not all patients who screen positive truly have a hereditary cancer syndrome; they simply require a referral for counseling and testing. If your pathology department does not offer these screening tests, consider speaking to decision makers there about incorporating this important technology, at least in early-onset cases.

		Table. Risk Factors for Hereditary Colon Cancer

					Refer for genetic counseling if the patient has a personal and/or family history of:

					Colon or endometrial (uterine) cancer diagnosed before the age of 50

					Multiple cases of colon, uterine, or ovarian cancer on the same side of the family

					Multiple and/or early-onset colon polyps, including greater than 15 gastrointestinal polyps, multiple polyposis, or greater than five hamartomatous or juvenile polyps

					Related cancers, tumors, and/or physical findings in an individual or on the same side of the family (colon/ uterine/ovarian/urinary tract cancers, or colon cancer/polyps/desmoid tumors/osteomas)

					Multiple primary colorectal and/or related cancers in one individual (eg, colon and uterine, synchronous/ metachronous colon cancers, colon and ovarian)

					Rare or unusual tumors or physical findings (including even one sebaceous carcinoma or adenoma, or CHRPE)

					Any HNPCC-related cancer/tumor (eg, colon, endometrial, sebaceous carcinoma) that is MSI-positive or demonstrates loss of an HNPCC-related gene product (ie, MLH1, MSH2, MSH6) by IHC

					Known genetic mutation in the family (eg, HNPCC or FAP)

	Genetic testing for colon cancer is evolving rapidly, and there will likely be more testing options within the next year. Presently, cases are split into two broad categories:

 (characterized by dozens, hundreds, or thousands of colon polyps):

		The number and types of polyps (adenomas, hamartomas, hyperplastic, etc) found determines which genes are likely involved. Obtaining pathology reports and a lifetime polyp count is therefore very important and can guide genetic testing.

		Multiple adenomatous polyps are most often associated with familial adenomatous polyposis (FAP). FAP can include osteomas, an eye finding called congenital hypertrophy of the retinal pigment epithelium (CHRPE), dental abnormalities, desmoid tumors, thyroid cancer, and medulloblastoma. All of these findings should be elicited when taking a pedigree.

		The best recognized is Lynch syndrome, also called hereditary non-polyposis colorectal cancer (HNPCC).

		Colon cancer is often right-sided and early onset.

		Patients are also at increased risk for endometrial and ovarian cancers, sebaceous adenomas and carcinomas, and urinary tract cancers. Questions about all of these cancers should be asked when taking a pedigree.

		Colon and uterine tumors can be tested (via IHC screening or assessment of MSI) for markers to determine if the patient is at increased risk for Lynch syndrome; then, the patient should be offered genetic testing.

	The oncology nurse can play an important role in taking a detailed personal and family history that includes all cancers, polyps, and related physical findings in order to determine which patients are at greatest risk for a hereditary cancer syndrome. Testing options for hereditary colon cancer will likely change with the advent of multiple gene panels and whole exome sequencing, so expect more testing options within the next two years.

	Ellen T. Matloff, MS, CGC, is a certified genetic counselor and director of Cancer Genetic Counseling at Yale Cancer Center, New Haven, Connecticut.

Genetic Counseling

Colon cancer is equally as likely as breast and ovarian cancer to be hereditary (approximately 10% of cases, overall) and there are many different genes responsible for these cases.

Hereditary Colon Cancer: Which Patients Are at High Risk?

 Diagnostic tests are common across the spectrum of cancer care, but results may not always be easily interpreted or applied clinically. In certain types of cancer, related conditions can interfere with the accuracy of diagnostic testing. Thus, it is important to choose the best test, taking into consideration timelines, invasive versus noninvasive testing methods, specificity (a test’s accuracy in identifying negative results), and sensitivity (a test’s accuracy in identifying positive results), two speakers said during a presentation at the ONS 37th Annual Congress.

	“Diagnostic tests have specific indications, contraindications, and circumstances that make their results inaccurate or uninterpretable. Use of diagnostic tests should appreciably offer information that can drive clinical decisions,” said Brenda K. Shelton, MS, RN, clinical nurse specialist at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins in Baltimore, Maryland. She spoke on the topic with Anna Antonowich- Jonnson, MSN, City of Hope, Duarte, California.

	The wealth of diagnostic tests related to cancer care includes lab tests, imaging tests (x-ray, ultrasound, CT, MRI, nuclear scans), and scopes that allow direct visualization of an anatomic area. Each test has a different purpose, and nurses should be aware of ideal indications, as well as contraindications. Among the variables that can confound diagnostic test results are age, gender, fluid balance, body fat, albumin, diet, medications, sexually transmitted diseases, and recreational drugs, Shelton said.

	Nurses who perform or prepare patients for diagnostic tests should be familiar with optimal technique, because suboptimal technique can lead to incorrect, incomplete, or questionable/uninterpretable results. Safety issues are also important, as is the need for special handling, she said.

	Some specific diagnostic tests that may be needed prior to initiation of cancer therapy are complete blood count (CBC) with differential, chemistry panel, renal function/urine studies (ie, glomerular filtration rate [GFR], serum creatinine test), and hepatic function tests, Shelton said. Equations and formulas for estimating GFR and serum creatinine level are available on the Internet.

	To illustrate a scenario in which a series of diagnostic tests would be needed, Antonowich- Jonnson reviewed the case history of a patient with colorectal cancer receiving capecitabine who was found to have anemia. Further tests, she said, would include CBC with differential, B

 level, iron tests, stool exam for guaiac and 

, and possibly, endoscopy and/or colonoscopy.

	She said that causes of anemia could include bleeding secondary to mucositis, hemorrhoids, or chemotherapy, and recommended that prior lab tests, medications, iron and ferritin levels, and other prior treatment be reviewed. Regarding guaiac stool testing, Antonowich-Jonnson said that oral iron supplements do not give false-positive results, but that intake of vitamin C, red meat, and dietary peroxidases (ie, turnips and radishes) can lead to false-negative results. She stated that an adequate stool sample is 10 mg/g.

	Although some institutions may use several stool samples to evaluate the presence of 

, only one sample is necessary, given the current accuracy of the stool test for toxin, Antonowich- Jonnson told listeners. Patients with diarrhea and suspected infection should be isolated until the diagnosis is established, she said, and outpatients and their families should be educated about appropriate hand hygiene and eliminating risks.

	Diagnostic tests have specific indications, contraindications, and circumstances that make their results inaccurate or uninterpretable. Use of diagnostic tests should appreciably offer information that can drive clinical decisions.”

	According to Antonowich-Jonnson, electrolytes should be assessed and adequate hydration ensured. After that, she said, the patient should be re-evaluated; blood transfusions are generally needed if hemoglobin level is <8, the hematocrit is <23, or the patient is symptomatic.

	Shelton and Antonowich-Jonnson reviewed other cases and discussed the considerations involved in selecting several diagnostic tests, including those for dysrhythmias, glucose abnormalities, blood cultures, neutropenia, brain natriuretic peptide, cardiac function, liver function, pulmonary function, 

	For any diagnostic test, Shelton said, interpreting the findings should include consideration of status of disease, severity of organ dysfunction, impact of disease status on current choice of treatment, undiagnosed comorbidity, differential diagnosis, additional tests that could be helpful, and essential preparation for diagnostic tests.

 as a resource to help nurses learn about diagnostic tests and access calculators for body surface area, corticosteroid conversion, opiate equianalgesics, carboplatin area under the curve, creatinine clearance, anion gap, and absolute neutrophil count status.

	“In addition to choosing the right diagnostic test, critical thinking and excellent assessment skills are needed,” Shelton said.

Diagnostic tests are common across the
spectrum of cancer care, but results may not
always be easily interpreted or applied
clinically.

Considerations in Interpreting Diagnostic Test Results

	Nurses involved in cancer care should be up to date on the growing number of applications for interventional radiology in oncology, since some centers may call upon them to work within the quickly developing area, a speaker suggested during the ONS 37th Annual Congress.

	In fact, the oncology nurse’s role is vital in the management of patients receiving such procedures, noted the speaker, Diana Wortham Maultsby, RN, an oncology clinical nurse specialist who works in Asheville, North Carolina as a clinical infusion data consultant for CareFusion, which is based in San Diego, California.

	Interventional radiological procedures entail the use of minimally invasive, image-guided, ablative strategies. In oncology, the strategies are typically aimed at reducing tumor volume, preventing cancer progression, and minimizing the risk of new tumor growth in nonsurgical populations with selectively advanced cancers. The procedures include radiofrequency ablation (RFA), chemoembolization, radioembolization, and high-intensity imageguided focused ultrasound (MRIgFUS), Wortham Maultsby said.

	The clinical results of interventional oncology can be comparable to those achieved through surgery, and these procedures are often effective options for medically and surgically ineligible patients, she said. They target cancerous tissue while sparing healthy adjacent tissue, and are associated with reduced side effects, lower morbidity and mortality, shorter hospital stays, fewer complications, and improved quality of life when given in conjunction with or instead of traditional treatment approaches. Procedural advantages of such treatments include the ability to identify targets with imaging and reduced resource utilization compared with conventional surgery, Wortham Maultsby said.

	Despite these potential advantages and the fact that there are about 6000 interventional radiologists in the United States, public awareness about these types of treatments is low, Wortham Maultsby said. Still, she said, there are a number of organizations developing guidelines and infrastructure to standardize the roles, services, reimbursement, and delivery models of care in interventional radiology. They include the American College of Radiology, The American Society of Interventional and Therapeutic Neuroradiology, and the Society of Interventional Radiology.

	Interventions that are image-guided include all thermal and cryoablation procedures and catheter-based delivery of chemoembolization and radioembolization, she said. For example, interventional radiologists commonly deploy embolization, cryoablation, and microwave and transarterial chemoembolization (TACE) for liver, prostate, lung, and gastrointestinal / colorectal cancers.

	Wortham Maultsby described more about such techniques:

	Radiofrequency thermal ablation (RFA) precisely delivers increasing levels of heat to tumor tissue with the aid of radiographic imaging (ultrasound, CT, or MRI), and the heat causes cell death. Current indications for RFA include liver and metastatic lesions, and the treatment will probably play a role in the management of other primary cancers, including renal, non-small cell lung cancer, adrenal, and breast cancers, as well as painful bone metastases. The technique can be used to treat patients who are otherwise not surgical candidates or who have failed other therapies. As with other interventional radiology techniques, potential advantages of RFA include lower rates of bleeding, shorter recovery times, and minimal side effects.

	Cryoablation utilizes a cryoprobe inserted into a tumor to deliver super-cooled gas that freezes the tumor tissue, and thereby achieves cellular death. Cryoablation is reimbursable through health insurance for prostate cancer and, in some states, for liver cancer. Use of cryoablation at other tumor sites, including the kidney and lungs, is considered investigational.

	MRIgFUS is being studied for the treatment of breast fibroadenomas and metastatic bone tumors, with promising results in phase III trials.

	Interventional vertebral augmentation can be achieved with percutaneous vertebroplasty or kyphoplasty for patients with symptomatic neoplastic and noncancerous vertebral compression fractures. The technique is proven to be as effective in the reduction of overall pain severity and improved mobility as conservative medical management.

	When TACE is used to treat liver tumors, the procedure is performed percutaneously in the angiographic suite, and combines intra-arterial delivery of chemotherapy plus embolic agents. Drug-eluting microspheres have been developed for use with TACE, allowing more precise delivery of chemotherapy into blood vessels surrounding the tumor, and giving the provider better control of bead placement for sustained and predictable dosing. Several clinical trials utilizing TACE with microspheres containing chemotherapy or radiation have been performed, with reliable and positive patient outcomes.

	In preparation for interventional procedures, most patients can expect to have IV fluids, premedications for symptom management, and either a radial or femoral arterial line for vascularbased approaches, or a probe or needle route for equipment introduction for nonvascular-based interventions to access the targeted treatment site. During the procedure, patients will need monitored sedation and local anesthetic with standard postprocedure care. Patients may need subsequent treatments for inoperable lesions, a decision that is typically made during an evaluation 4 to 6 weeks post-procedure.

	Interventional radiology procedures are a burgeoning area in oncology, and professional competency will be needed to meet the growing demand for these treatments, Wortham Maultsby emphasized.

	“A multidisciplinary approach—including the nurse&mdash;is vital to success,” she said.

Nurses involved in cancer care should be up to date on the growing number of applications for interventional radiology in oncology, since some centers may call upon them to work within the quickly developing area.

Interventional Radiology: A New Frontier in Cancer Care

	Imagine for a moment that you are a young, healthy, vibrant wife and mother who goes to the emergency room for abdominal pain and bloating. You are expecting to have a GI workup and to be sent home with a medication for gastric reflux. Several tests are done: labs; a CT scan of the chest, abdomen, and pelvis; and a paracentesis to remove the extra fluid that is causing the bloating. The simple ER visit turns into an admission to the hospital for further workup, and the outcome is a diagnosis of ovarian cancer with metastasis to the liver. You suddenly change from a woman in control of her health and well-being to a shocked, frightened, overwhelmed patient who hears the word “cancer” but does not fully understand what it means. Oncology, surgery, chemotherapy, and radiation are words you never imagined in your personal health vocabulary. Your focus shifts from the diagnosis to the prognosis, and from thoughts of your own well-being to thoughts of your husband, your children, and your career. How stressful would this be?

	Think now about being a middle-aged man who has just returned from running a marathon. You and your coworkers at the fitness center that you own and operate are training for a triathlon in 6 months. You go for your yearly checkup with your primary-care physician and have blood work, a cardiac stress test, a digital prostate exam, and a routine physical. Your doctor notices an enlarged prostate gland on exam and adds a prostate-specific antigen (PSA) level to the blood work. You leave the office and don’t think much about it until you get a call a week later from the medical assistant, who tells you that you will need to consult an oncologist for your prostate cancer. You have no family history of cancer, you don’t understand what an elevated PSA means, and, frankly, you don’t have time to be sick. All you can think about is how this diagnosis will impact your running and how reasonable it would be to put off treatment until the triathlon is over. How stressful would this be?

	Now picture yourself as a new grandmother, recently retired after a 40-year career as a business professional. You are enjoying spending time with the new baby but seem to feel a bit more fatigued than you are used to. You develop a cold that just seems to linger on. The cold turns into an upper respiratory infection with an annoying cough. You see your family doctor, who prescribes an antibiotic. Two weeks after completing the medicine, the cough is not going away. Suspecting pneumonia, your doctor orders a chest x-ray. When you are called in to discuss the results, a bombshell is dropped: You have suspicious lesions in your lungs. You are referred to an oncologist, who orders subsequent tests including biopsies; a PET scan of the chest, abdomen and pelvis; and blood work. In the process of going through the tests, you develop significant pain in several areas on your spine. When you meet with the oncologist to discuss the results of the tests, you are told that you have non-small cell lung cancer with lymph node involvement and metastasis to the bone. If this wasn’t devastating enough, this is the same diagnosis that your husband received less than 2 years ago. You saw him suffer and change from a strong man into a weak, frail individual who left this world much too soon. How stressful would this be?

	How stressful any of these situations would be depends largely on the individual faced with the situation. Distress is an underestimated, difficult-to-define, and unique response; how stressful something is for one person does not predict how stressful the same situation will be for another. Distress is, however, something that every cancer patient deals with. One goal for a successful nurse navigator program is to be able to recognize distress as a condition that plays a large part in the patient’s cancer journey. With that insight, a navigator can help the patient alleviate the distress, navigate through the rough patches, and focus on his or her health and well-being. To be most helpful, the nurse navigator needs to quickly recognize the patient’s health and financial concerns, psychosocial needs, coping mechanisms, and support system, as well as any cultural influences or religious beliefs that may impact care. The nurse navigator has to identify barriers to treatment so that the patient can get the most appropriate care as quickly as possible.

	At Banner MD Anderson Cancer Center (BMDACC) in Gilbert, Arizona, the nurse navigator program is just getting under way. Since its debut in September 2011, the program has changed multiple times, and the process by which patients navigate through the system has been a moving target. Initially, the nurse navigator, who is an oncology nurse in a case manager’s role, would meet the patients after they had consulted with financial services. This allowed the navigator to assist right up front if high copays or insurance concerns (such as the requirement for prior authorization) were identified.

	Meeting early on also gave the nurse and patient time to form a relationship and to build trust in one another. The navigator could assess the support system, the family dynamics, and the patient’s coping mechanisms. Ideally, the nurse navigator would obtain important information on the initial visit that could be relayed to the appropriate staff, such as social worker, dietitian, physical therapist, or physician. The nurse would gather treatment information, including the patient’s understanding of his or her diagnosis and prognosis; family history of cancer; past surgery, chemotherapy, or radiation treatment; and any medical records or scans the patient had on hand.

	In theory, this meeting prior to the patient seeing the physician was a good idea, but every good idea has its drawbacks. BMDACC nurse navigators recognized that too much time was being spent with patients who were only getting a second opinion; patients who were not returning for treatment were not going to need the nurse navigator, and the time spent on those patients was time taken away from the patients who really needed assistance.

	Meeting the patients ahead of time occasionally made the patients late for the physician visit, causing both the patient and the physician to feel rushed. The anxiety level of patients facing a cancer diagnosis was so high that a large portion of what the navigators were saying so early in the process was not being heard. We recognized that a different approach was indicated to better provide for the needs of our patients.

	Therefore, the nurse navigators switched gears and began seeing the patients after they met with the physician. This allowed the nurse navigator and physician to better communicate regarding the patient’s treatment plan and address distress concerns.

	Regardless of when patients are seen by nurse navigators, at BMDACC, the distress level of the patient and his or her loved ones is considered very relevant to the treatment plan and to the care received. Any navigator program should address distress as one of its key components in order to be effective. The caring, nurturing, and compassionate traits that go along with nursing also need to be incorporated into navigation programs. Cancer patients deserve medical treatment for their cancer and distress relief from their nurse navigator.

Nurse Navigators

One goal for a successful nurse navigator program is to be able to recognize distress as a condition that plays a large part in the patient's cancer journey.

Distress and the Nurse Navigator, Part I

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

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

		Louisiana State Health Sciences Center in New Orleans, Louisiana

	It’s that time of year again, when you’ve either had the opportunity to attend the Oncology Nursing Society (ONS) Annual Congress, or you’ve been the one who stayed home to take care of patients. Whether you attended the meeting or not, it’s springtime and a good time to get recharged and stay current in oncology nursing.

	Staying current is challenging. Many new cancer drugs and supportive agents are now being used in practice, and research in many areas of interest to oncology nurses (eg, symptom management, psychosocial issues, quality of life) is proliferating. When I ran into an oncologist who had retired and I asked why, his reply was that he no longer could pronounce the names of the drugs. Fortunately, we have resources, such as the ONS Annual Congress, that help us keep up.

	The ONS 37th Annual Congress offered a wide array of information. There was a lecture on optimizing patient outcomes in light of advances in treating renal cell carcinoma, and another on BRAF inhibition in melanoma and its application in other cancers. Also offered were an overview of recently approved pharmacologic agents and a talk on helping patients and families cope with cancer. A plethora of congress sessions and satellite symposia delved into topics including translating research into practice; genomic competency; managing lymphedema; evidence-based practice; nutrition; the value of electronic health records; staffing ratios; infection in the neutropenic patient; and challenging cases in breast cancer and multiple myeloma.

	Keynote speaker Brenda Elsagher, a speaker, author, and comedian, offered insight into the struggles a cancer patient experiences and what can bring comfort, as well as ways for nurses to discuss “taboo” subjects with their patients.

	Finally, the achievements of five of our colleagues were recognized during the event. Among them was Carol Reed Ash, EDD, RN, FAAN, who received the ONS Lifetime Achievement Award. Ash is professor emeritus, Kirbo Endowed Chair, Oncology Nursing at the University of Florida in Gainesville. The award recognizes her outstanding contributions as a researcher, mentor, and educator, as well as her service to ONS and the community.

	For the lucky ones who attended this comprehensive meeting, it was easy not only to learn the latest findings, but also to be inspired by thousands of passionate oncology nurses.”

	For the lucky ones who attended this comprehensive meeting, it was easy not only to learn the latest findings, but also to be inspired by thousands of passionate oncology nurses. The congress offers so many opportunities—for networking, for renewing friendships, and for self-development. It draws attendees from all over the map, so there also are opportunities to meet international nurses and learn how oncology care is delivered in other parts of the world. It’s a reminder that, although the US healthcare system is sometimes described as broken and inadequate, it is far more advanced than systems in underdeveloped countries, where even basic pain management is not available to patients.

	This year’s congress was held where I live, in New Orleans, and the theme of the meeting was “get jazzed.” Getting pumped up in “N’Awlins” is a pretty easy thing to do, especially when the ONS Congress coincides with the world-renowned New Orleans Jazz Fest. The Jazz Fest is known for its food as much as its music; it’s been said that you can’t get a bad meal in New Orleans, and I believe that’s true. Having the ONS Congress in New Orleans during Jazz Fest is what we call 

	For everyone who wasn’t able to attend the meeting, spring is a good time for you to seek out a little something extra, too. If nurses from your workplace attended the meeting, I hope they’ve come back with new information and renewed energy, and that they’ve shared what they learned with you. There are also other ways to “keep up with congress.” The ONS website, www.ons.org, has meeting recaps and information posted in its “conference” section. Audiotapes from the congress are available for purchase. Other resources include congress coverage and continuing education opportunities in 

	The breadth and depth of new information you’ll find is definitely something to “get jazzed” about.

	And if you missed the chance to enjoy some crawfish and music along with your opportunity to learn, I encourage you to find a chance to relax right where you are. Take advantage of springtime and go outside to enjoy nature.

	Our patients depend on oncology nurses who are not only well informed and current in their knowledge, but who are also calm and composed.

Nurse's Notes

For the lucky ones who attended the ONS 37th Annual Congress, it was easy not only to learn the latest findings, but also to be inspired by thousands of passionate oncology nurses. 

June 2012