While competition is the hallmark of the powerhouse sports teams of the Big Ten Conference, collaboration will be the key for a research initiative recently launched by cancer centers at most of the same universities.

The Big Ten Cancer Research Consortium will cooperate on clinical trials, with a particular emphasis on molecular diagnostics, in an effort that is expected to generate advancements as well as expand opportunities for junior faculty and fellows, officials said in announcing the new group in Chicago.

“This is a rare opportunity for the universities to work together as part of a regional team science initiative to advance cancer research,” said Patrick J. Loehrer, Sr, MD, director of the Indiana University Melvin and Bren Simon Cancer Center, in a statement. “The advantage of this, particularly during a time of austerity for research, is that we can build upon the strengths of the institutions and fortify some of the shortcomings. This allows us to be lean, efficient, but most importantly, collaborative.”

The following cancer centers and universities have joined the consortium:

		Indiana University Melvin and Bren Simon Cancer Center

		Robert H. Lurie Comprehensive Cancer Center at Northwestern University

		Purdue University Center for Cancer Research

		The Cancer Institute of New Jersey, scheduled to become part of Rutgers University in July (Rutgers also is set to join the Big Ten Conference in 2014)

		Holden Comprehensive Cancer Center at the University of Iowa

		University of Michigan Comprehensive Cancer Center

		Masonic Cancer Center at the University of Minnesota

		Fred & Pamela Buffett Cancer Center at the University of Nebraska

		Carbone Comprehensive Cancer Center at the University of Wisconsin

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Updates

Big Ten Cancer Centers Form Research Group

A grant from a pharmaceutical company is translating into a win for both the University Medical Center of Princeton at Plainsboro (UMCPP) and its patients with cancer.

Under the grant from Bristol-Myers Squibb, the medical center in New Jersey has hired a full-time oncology nurse navigator to guide patients through the complexities of their experience with cancer, and is working collaboratively on that effort with another grant winner, the American Cancer Society (ACS) Eastern Division.

Ultimately, leaders of the hospital’s navigation program expect the effort will not only help patients cope with their disease and its ramifications, but encourage them to receive all of their treatments at UMCPP, boosting the size of the patient population at the medical center’s new facility, which opened a year ago.

“It’s part of having patients at the center of the care, and that is how the healthcare system and reimbursement are moving,” said Judy Neuman, CTR, director of Cancer Services at UMCPP’s Edward & Marie Matthews Center for Cancer Care. “Supportive services have proven to bring better outcomes, so my vision is that it’s important to provide as many as we can.”

At the same time, Neuman said, the pilot program is designed to prove that there’s a fiscal argument for keeping a navigator on staff. “Once we can quantify that” for hospital administrators, she said, “they’ll be able to say that it’s worth putting our funds into that area.”

Launched in January and partially funded by the one-time $50,000 grant, the oncology nurse navigation program at the cancer center consists of a single, full-time senior oncology nurse navigator, Lori McMullen, RN, MSN, OCN. The establishment of her position represents an expansion of the navigation program run by the hospital’s parent company, Princeton HealthCare System, which previously consisted of one breast health navigator at its Plainsboro Breast Health Center in East Windsor.

Since coming on board, McMullen has been seeing a growing number of patients—the number has risen to 60&mdash;and is available to help them, at no extra charge, to deal with anxiety and fear about their cancer; arrange for transportation to chemotherapy appointments, home meal delivery, home cleaning, or other supportive resources; find financial assistance or arrange payment plans; learn about their conditions or side effects of treatments; or even locate inexpensive funeral services.

“I see patients through the whole cancer trajectory, although the most opportune time is when they’re first told they have cancer or a positive biopsy,” McMullen said. “I can help keep them moving forward and get them through the system without getting stalled, shepherd them into treatment, and empower them to make decisions, such as getting a second opinion.”

Under the grant, McMullen is also designing an orientation program for patients who are set to undergo radiation or chemotherapy, which will consist of a meeting, tour, talk, and binder full of printed materials about the cancer center’s services.

To supplement her work, McMullen is being assisted two mornings each week by a lay navigator from the ACS Eastern Division—funded through a related $125,000 Bristol-Myers Squibb grant&mdash;who visits UMCPP to check in with patients and either help them resolve problems or refer them for nurse navigation. ACS is also providing that service to other area hospitals via the grant.

Together, UMCPP and ACS also collaborate to offer the “Look Good Feel Better” program, through which cosmetics companies donate products, and training in their application, to patients undergoing chemotherapy, who are often upset not only by the loss of their hair, but of their eyebrows and eyelashes.

Both the Princeton HealthCare System Foundation (on behalf of UMCPP) and ACS received their grants after submitting unsolicited requests for the projects, which Bristol-Myers Squibb considered complementary. The pharmaceutical company, whose US operations are based in Plainsboro, is one of the medical center’s neighbors.

“Bringing together organizations with common goals, similar programs, and potentially complementary services can lead to efficiencies in immediately tangible ways,” said Murdo Gordon, senior vice president of US Pharmaceuticals at Bristol- Myers Squibb. “With the coming changes of the Affordable Care Act, the financial impact on organizations and individuals will likely be profound, and the entire cancer community will need to work together to address these concerns. Collaborative approaches, such as those being taken by UMCPP and the American Cancer Society, which bring together meaningful services from various providers to support a given community, is a refreshing solution.”

So far, Neuman said, the program is working well.

“The feedback from the entire hospital has been nothing short of wonderful,” she said. “The nurses feel it has helped their patients, and the chief nursing officer has commented on the value it brings to our facility and patients.”

		The infusion room at the University Medical Center of Princeton at Plainsboro.

Since arriving at UMCPP, McMullen has been working to ensure that staff members are aware of the services she can provide.

“It’s a new position in an established hospital, so getting the rest of the facility to understand what I do and how I can help will take time,” she said.

While staff members within the cancer center know about McMullen, doctors in other parts of the UMCPP building—who also might diagnose cancers&mdash; are less aware.

“I’ve been going to staff and section meetings and physicians’ offices to tell them I’m here, as well as working with the nurses,” McMullen said.

Ultimately, Neuman would like to expand the program to include enough navigators to handle the hospital’s entire caseload of about 900 patients per year who are diagnosed with cancer and about 200 per year who return to the facility to have their cancers treated.

“It’s important to have some kind of touch with all of them, although they don’t all need it,” McMullen agreed. “Some patients come out of the womb empowered, and some need help every little step of the way.”

To make that vision a reality, Neuman said, she hopes to use the pilot program with McMullen to prove to the hospital’s leaders that navigation more than pays for itself.

McMullen has begun the process by starting to assess patient satisfaction with her services, and has found the early results promising.

In a survey, McMullen asked patients diagnosed with cancer at UMCPP whether the facility’s navigation services had affected their decision about whether to stay on to receive their cancer treatments. She sent out 22 surveys in a 6-week period, and received five back; among them were two from patients who said they’d stayed at UMCPP because of its oncology navigation program.

“Eventually, we’ll be able to look at the downstream revenue from having navigation services,” McMullen said.

“Even just the two patients we know of who stayed due to the navigation program can represent a substantial amount of money to the system,” Neuman added.

For McMullen, navigating at UMCPP’s cancer center has already been very rewarding.

McMullen has helped to transition a couple of patients into end-of-life care, and is glad she was able to aid them and their families in having difficult but necessary conversations at a time when they didn’t know where else to turn.

	In many other cases, McMullen’s efforts are focused on helping patients to live as well as possible. She has been able to help resolve problems with symptom management and disease process, sometimes answering questions patients were too shy to bring to their doctors.

			Lori McMullen, RN, MSN, OCN, seated, and Judy Neuman, CTR, of the University Medical Center of Princeton at Plainsboro.

	“Cancer is complicated,” the navigator said. “A doctor might tell a patient he has colon cancer, but there are different stages and treatments. I can help patients understand their treatment plans, and that what they find on the Internet might not apply.”

	McMullen is also focused on letting patients know there is support for them outside the hospital, as well as within the facility.

	Jeff Descoteau, whose mother undergoes treatment for cancer at UMCPP, said McMullen relieved their stress by helping them understand treatment options and available resources.

	She also explained which expenses were covered by insurance or secondary insurance, and informed the family about national programs that offer financial aid, as well as potential assistance with the cost of prescriptions. She made them aware of in-home services, including medical care and help with household tasks, and connected them with transportation services for medical visits or treatments.

	“Lori McMullen is an angel in our eyes,” Descoteau said. “She took the time to learn of our personal situation, and she not only shared her knowledge about the resources available to us, but also did the legwork to get the results we needed for any situation. With her assistance, my mom was able to focus on what she needed to do to get back to a normal life. And I was able to focus on what is most important to me: my mom.”

Feature Story

A grant from a pharmaceutical company is translating into a win for both the University Medical Center of Princeton at Plainsboro and its patients with cancer.

Navigation Program Proves a Win-Win for Patients and Medical Center

If the job of oncology nurse comes with satisfactions— the gratitude from patients and family members for compassionate care rendered, shared happiness with patients who experience good outcomes&mdash; it also comes with an abundance of stress, even more than what oncologists and other medical professionals experience, according to research.

The stress can lead to burnout and to “compassion fatigue,” compromising job satisfaction and careers, and damaging personal lives.

Because they are working with patients “at one of the most significant times of their lives,” it is common for oncology nurses to develop an unusual closeness, said Penny Damaskos, PhD, LCSW, OSW-C, program coordinator and clinical supervisor at Memorial Sloan-Kettering Cancer Center (MSKCC), speaking as part of a panel on compassion fatigue at the 38th Annual ONS Congress.

Physical symptoms as well as psychological ones may appear in nurses as a result, often with impacts both at home and at work—where lowered productivity, increased work absenteeism, or leaving the work setting altogether have been reported under these circumstances (

		Lowered frustration tolerance/increased outbursts of anger or rage

		Self-destructive, self-loathing behaviors

		Difficulty separating work from personal life

		Patient’s suffering mirrored in helper (eg, loss of hope, intrusive thoughts, feelings of helplessness)

Damaskos and others on the panel discussed how compassion fatigue arises from the desire to relieve another person’s suffering. Differing from “burnout” which is grounded in nurses’ reaction to the work environment (although there are shared symptoms), compassion fatigue has its source in the clinical work itself, and in the manner by which nurses internalize interactions with patients. For an oncology nurse, interactions with cancer patients, especially those who are hospitalized, often conclude with loss (of patients to death) and to internalized grief. From constant exposure to the suffering of fellow human beings, nurses may develop feelings of helplessness.

The scope and range of recent published research on compassion fatigue and burnout are evidence of the urgency of these issues to the field of oncology nursing. A search using Google Scholar returned 493 results since 2009, according to panelist Katherine Janzen, RN, MN, ONC-C, assistant professor, School of Nursing at Mount Royal University in Calgary, Canada. Proquest and the Allied Health Database contain 284 articles on compassion fatigue in oncology nurses. Among themes that recur is the recognition of compassion fatigue as an imperative nursing agenda item for action and intervention.

Panelist Katrina Fetter, BSN, RN, OCN, staff nurse and assistant manager at Lancaster General Hospital in Pennsylvania, pointed to her institution’s successful strategies to deal with compassion fatigue. Lessons from this experience, she said, include instituting an open dialogue with staff on the subject of stress and its consequences and a process of regular reevaluation. Build a formal program that is supported by the literature, Fetter advised, but “remain flexible,” to better respond to specific problems as they arise.

The end goal for nurses, said Fetter, is to develop healthy, therapeutic relationships with patients, but also to protect themselves by cultivating emotional boundaries.

Memorial Sloan-Kettering Cancer Center has incorporated within its system an “institution-wide” push toward recognition of staff burnout and promotion of wellness, said Damaskos. Institution-wide seminars and respite programs and a partnership between Employee Wellness and the Department of Social Work have been incorporated within the hospital system. At the level of the individual, she said, there are support groups on inpatient units and in outpatient facilities to address job stressors, and these services are available to all staff.

Among several other initiatives at MSKCC, Damaskos described an ambulatory nursing program, which has explored such topics as “Bereavement: Coping for Healthcare Professionals,” “Therapeutic Communication: Discussions about Death and Dying,” and “Compassion Fatigue, Burnout and Resilience.” Also at MSKCC, a peer-to-peer pilot project has been launched for nurses to promote self-awareness of the impact of their work and to serve as an opportunity for discussion of topics central to maximizing their productivity, sensitivity, and resilience— including maintaining positivity, fostering emotional insight, and life balance and spirituality.

: leave work at work, recognizing that compassion fatigue and burnout are part of the job description. Allow for respite times within work days as well as outside of work.

Build supportive professional relationships

 and networks through professional and educational support systems (eg, mentors).

in professional and personal life. Get involved in projects that interest you. Focus on mentoring others.

			Gentry JE, Baranowsky AB, Dunning K. ARP: the accelerated recovery program (ARP) for compassion fatigue. In: Figley CR, editor. Treating Compassion Fatigue. New York: Brunner-Routledge; 2002:123-137.

			Jackson D, Firtko A, Edenborough M. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. 

Conference Highlights

If the job of oncology nurse comes with satisfactions it also comes with an abundance of stress, even more than what oncologists and other medical professionals experience, according to research.

Compassion Fatigue and the Challenge of Developing Resilience

With more and more cancer therapies being administered as oral agents, oncology nurses have a critical role to play in helping their patients to manage their medications and any side effects of treatment. Among the poster presentations at this year’s ONS Congress were several focused on how oncology nursing professionals can aid patients in adhering to their oral regimens, as well as encourage their patients to report any adverse events.

	Toolkit Helps Patients Manage Oral Regimens

To improve adherence to oral chemotherapy treatment schedules, nurses at The Cancer Institute of New Jersey created a patient-friendly toolkit. Using evidence-based guidelines and gathering patient recommendations and feedback on the topic, they developed a screening technique to identify barriers to therapy adherence. When creating the toolkit, nurses added a color-coded pill diary with instructions, individualized calendars specific to a patient’s treatment regimen, and an education sheet about taking oral chemother-apy, which reviews safe handling procedures.

“Non-adherence to oral therapy has been shown to reduce treatment success, which could lead to additional doctor visits or even hospitalizations. By providing this set of easy-to-use tools, clinicians can help empower patients during each interaction,” noted lead author Yuk (Aggie) Wong, RN, BSN, OCN, MA. Wong, along with colleagues Pamela Scott, RN, OCN, and Heather Camisa, RN, BSN, OCN, plans to further evaluate the new toolkit via chart audits and patient/staff surveys. (

	Proactive AE Management Optimizes Adherence

Patients with metastatic colorectal cancer (mCRC) taking the oral multikinase inhibitor regorafenib demonstrated a low discontinuation rate due to treatment-related adverse events (AEs), according to results of the phase III CORRECT clinical trial, suggesting that many AEs can be managed successfully to optimize treatment adherence.

Taline Khoukaz, MSN, ACNP-C, with the USC Norris Comprehensive Cancer Center, and Jessica Mitchell, RN, CNP, of the Mayo Clinic, looked at the potential for patient education and proactive symptom support measures to address some of the more common AEs experienced by mCRC patients being treated with regorafenib, among these, hand-foot skin reactions. They found that such skin reactions can be prevented or managed by implementing prophylactic strategies, including stringent patient monitoring, proactive supportive measures (eg, regular use of emollient creams, removal of calluses, and protection of tender areas and pressure points with thick gloves and socks), frequent clinic visits early on, plus AE patient education and reinforcement.

Proactive interventions were analyzed for other AEs (hypertension, liver abnormalities, oral mucositis, diarrhea, and fatigue), with the investigators concluding that, “proactive AE management may improve the patient’s treatment experience and maximize patient adherence, allowing patients to continue their regorafenib therapy with minimal interference in their daily lives.” (

	A Standardized Nursing Protocol for Oral Chemotherapy

Researchers at Wayne State University and the Karmanos Cancer Center are developing a comprehensive, evidence-based Oral Chemotherapy Nursing Practice Protocol focused on patient education, symptom assessment/management with follow-up calls, and continuing adherence monitoring. Early data gathered from audits of retrospective clinic charts at the gastrointestinal oncology clinic where the protocol was pilot-tested, show that it has increased documentation of: patient education by 84.3%, follow-up calls and early symptom assessment by 67.7%, and adherence monitoring by 42.4%.

Heejin Kim, RN, MSN, OCN, and colleagues, noted that previous benchmarking data revealed “inconsistencies in nursing procedure, adherence monitoring, and documentation of care for patients receiving oral chemotherapy,” suggesting the need for a standardized protocol. They noted that their findings “provide evidence supporting utilization of nursing standards to improve care for patients receiving oral chemotherapy.” (

With more and more cancer therapies being administered as oral agents, oncology nurses have a critical role to play in helping their patients to manage their medications and any side effects of treatment.

Research Focuses on Helping Patients to Manage Oral Medications

Improving communication, building relationships, coordinating activities among units, and engaging staff members are not only ways to create a more positive working environment, they are critical for maintaining patient safety. Engaged nurses are more likely to notice and take action when there is an opportunity to improve patient care.

In 2010, the Oncology Nursing Cluster of Smilow Cancer Hospital at Yale-New Haven in Connecticut identified the need for an informative website to support oncology nurses. The cluster consists of staff nurses who represent each of the inpatient and outpatient units within Smilow Cancer Hospital as part of the shared governance structure for nurses at Yale-New Haven Hospital (YNHH). With the support of senior leadership, two oncology nurses who were members of the Staff Nurse Council of YNHH took on the task of creating the website.

The idea was to create a comprehensive resource designed to achieve multiple, integrated goals. Building from our own nursing experiences, we further developed the concept by soliciting suggestions from staff and oncology nurse educators. We were trained in Web design by hospital information technology staff. After final administration review and approval, the oncology nursing website went live in March of 2011. The goals of the oncology nursing website include:

Evidence-based information at the bedside

: Our core goal was to improve patient care by helping Smilow nurses anticipate patient problems and provide better patient and family education by making available in real time at the bedside, searchable and printable teaching tools, such as best practices information, nurse-driven research projects, and links to policies, procedures, journal articles, and websites.

: The website includes resources to facilitate career advancement, such as tools for new nurses, a monthly education calendar, and links to journal articles and information about certification.

Team building and improved inter-unit communication

: This is a forum to celebrate achievements of individual nurses and nurse-generated innovations and spotlight unit quality initiatives and profiles of oncology nurses who serve as role models for others. We post staff-generated monthly slide shows so that nurses in each unit can get to know each other and learn about safety and quality initiatives on their sister units.

: A mechanism to disseminate timely, consistent information and for management to communicate new policy directives.

Next, we needed to build awareness and usage. We sought to draw people in by making the site easy to access by any nurse from the clinical workstation, pleasing to look at, and easy to navigate. We encourage repeat usage by rewarding users with useful, entertaining, up-to-date information.

The cluster members created a presentation “road show,” which they took to each unit in Smilow to build awareness of the website and to teach staff members how to access and use the information featured on it. Information on the site was incorporated into new staff orientation. A direct link/permanent icon was established to the site from the homepage of most of the clinical workstations at YNHH, permitting easy access to the site. The website is updated weekly with ongoing support from the University Information Technology Service and Yale University Medical School librarians.

As part of our ongoing effort to improve the site’s effectiveness, we conducted a staff survey after the site was online for a year. We surveyed 56 nurses— more than 25% of the total staff. We included nurses from all eight inpatient and outpatient clinics, including both day and night shifts. We found that 90% of the nurses surveyed (n = 49) had visited the site over the prior 3 months.

Partner Perspectives

Improving communication, building relationships, coordinating activities among units, and engaging staff members are not only ways to create a more positive working environment, they are critical for maintaining patient safety.

Nurse-Driven Website Empowers Nurses to Improve Patient Care

Complementary and alternative medicine (CAM) has been in the mainstream of healthcare for thousands of years in China, and in India where Ayurveda has long been practiced as a holistic approach to health, based on maintaining balance in body, mind, and consciousness through proper diet and lifestyle, as well as herbal remedies.

Now, in the United States, a growing proportion of cancer patients and cancer survivors are adopting CAM diets and taking herbs, vitamins, and supplements for their healing propertiesâ€”not in place of standard cancer therapy, but along with it and beyond treatment.

In this setting, research shows, the hope and promise of CAM nutrition comes with varying degrees of supportive evidence. But CAM and the concept of integrative care has joined the elite among medical research areas with a special unit within the National Institutes of Health: the National Center for Complementary and Alternative Medicine (NCCAM [

As much as 44% of all cancer survivors use CAM therapies, according to findings from a study by Judith Fouladbakhsh, PhD, APRN, and colleagues. Fouladbakhsh, associate professor at Wayne State University College of Nursing, and Liana Wheatley, BA, RN, OCN, a medical oncology nurse from Texas Oncology, reviewed the potential benefits and risks of CAM diets and nutritional supplements for cancer and other wellness goals at ONS 2013.

Anticancer diets, although they differ in guiding philosophies, use of specific supplements, food preparation (if any), and other particulars, typically share certain features. Most recommend high levels of antioxidants and phytochemicals, which are biologically active compounds found in plant-based foods such as fruits, vegetables, beans, and grains. Thousands of phytochemicals have been identified, but only a small fraction has received close scientific examination and verification of health benefits. Better known among the scientifically validated compounds are beta carotene and other carotenoids, ascorbic acid (vitamin C), folic acid, and vitamin E.

Also common among anticancer and other CAM diets is a recommendation for plant-based (vs animal-sourced) protein as well as fiber, omega-3 and omega-6 fatty acids and oils, minerals, and polyphenols, which are found in green tea, and curcumin (the major component of turmeric). Among a number of CAM diets discussed by Fouladbakhsh and Wheatley in their ONS overview, certain ones are labeled as â€œanticancerâ€ diets, including the Dr. Oz Anti-Cancer Diet, Dr. Moermanâ€™s Anti-Cancer Diet, The Makerâ€™s Diet, and the Paleo Diet.

Herbs have been used for thousands of years as a form of healthcare, and evidence is accumulating in support of the potential of some to affect cancer risk and progression at the cellular level. Examples include resveratrol, a phytonutrient found in grapes (and red wine), cranberries, blueberries, and other foods; ginseng, which contains saponins, which possess antitumor effects, such as antiangiogenesis; ginkgo biloba, for its gene-regulatory and anti-angiogenic properties; lycopene (found in tomatoes), which may affect cancer risk; and green tea, which contains polyphenols and catechins that can inhibit cancer cell growth and proliferation.

Integrative medicine and incorporating standard medicine with CAM is â€œwhere itâ€™s all going,â€ according to some nursing professionals. But there are also risks, especially to cancer patients. As NCCAM points out, these include evidence for interference with some standard cancer treatments.

Experts agree that the research basis for CAM diets and supplements is still inconclusive and that more extensive, randomized clinical trials are needed (

. 2010;51(8):1414-1423). Clinical practice guidelines for integrative oncology (

 2009;7(3):85-120) make these cautions specific, saying that, based on a review of the literature, â€œ...specific dietary supplements are not recommended for cancer preventionâ€ and that providers should evaluate a patientâ€™s use of dietary supplements prior to the start of therapy to assess for possible side effects and interactions.

A growing proportion of cancer patients and cancer survivors are adopting CAM diets and taking herbs, vitamins, and supplements for their healing properties-not in place of standard cancer therapy, but along with it and beyond treatment.

Patients and Survivors Harness the Healing Potential of Diets, Herbs, and Supplements

Any woman, upon receiving news of an inherited form of gynecologic cancer, may be justified in feeling that she faces a form of double-jeopardy—not only a cancer diagnosis but one that may place her family at a higher-than-average risk of a potentially deadly disease.

Enter the oncology nurse navigator, a professional designation new enough that its core competencies are still under development, but who can draw on genetic and genomic competencies for which all nurses are responsible. Essential competencies in genetics/genomics were only recently defined for the baccalaureate-level nurse by the American Nurses Association (ANA) in 2005 and for nurses with graduate degrees in 2012.

Still, cancer centers are responding to a need made manifest by advances in the sciences of genetics/ genomics, the availability of precise genetic testing and the ongoing development of new targeted therapies.

Fox Chase Cancer Center (FCCC) in Philadelphia and Northside Hospital Cancer Institute in Atlanta have established model oncology nurse navigator programs with integrated processes for assessment, identification, referral, education, care, and support for patients whose gynecologic cancers may be genetically-based.

The Fox Chase GYN navigation program was piloted at the end of 2010 with one nurse navigator in a part-time role. That role was expanded to a full-time position about 1 year later, and a second navigator was added in 2013 to manage/navigate a volume of 70 to 90 new patients each month, according to Carol Cherry, MSN, RN, AOCNS, APNG, and herself a GYN oncology nurse navigator there.

A map of the interface among healthcare professionals at FCCC reveals the complexity of navigating care for a GYN cancer patient. At FCCC, the GYN oncology nurse navigator functions within a service line model that includes dedicated gynecologic oncology surgeons, medical oncologists, radiation oncologists, nurse practitioners, RNs, nursing aides, surgical, medical, and radiation oncology fellows, social workers, GYN-focused clinical trials staff, an RN administrator from the Women’s Cancer Center, a risk assessment RN, and a GYN pathologist.

The FCCC program has measured its success by recognized metrics, and it has been shown to be worth the investment of time and resources (Box).

Cherry explained the opportunities to incorporate genetics/genomics in the navigator role. These include:

		Recognizing family history red flags and alerting clinical staff.

		Facilitating referral to Clinical Genetics at the hospital prior to or in conjunction with the GYN appointment.

		Tracking results of microsatellite instability analysis and immunohistochemistry (IHC) of endometrial tumors.

		Meeting patients in the clinic as needed following endometrial tumor testing.

New at FCCC, as of 2011, is a universal Lynch Syndrome screening strategy. All new patients with surgically resected or biopsied endometrial and colorectal cancers receive IHC as the primary mismatch repair (MMR) screen. If IHC shows a loss of PMS2, MSH2, and/or MSH6, patients are referred for genetic counseling. The navigator, whose background includes working in Clinical Genetics, helps facilitate referrals.

Penny Daugherty, RN, MS, OCN, oncology nurse navigator at Northside Hospital Cancer Institute, emphasized the role of patient support and partnership. This support begins early. Upon a patient’s first learning of a genetically-based cancer, she said, “what’s important is to quell panic,” and to “partner with the patient in reestablishing a sense of control.”

Another early step in the caregiving provided by the nurse navigator is to assess the readiness of the patient to accept and process information about genetic counseling—all the while maintaining an acute awareness of signs of distress. During a conversation with the patient and perhaps loved ones, Daugherty said (and demonstrated in a sample dialogue), “…maintain an awareness of the patient’s body language, especially indicators of fear, resistance, or avoidance” and provide reassurance.

Before concluding this first meeting, Northside nurse navigator/genetics counselors offer patients a FAQ sheet with a pen and notes page, along with instructions to read and jot down questions or comments, which, as the counselor explains, “…we will explore at the next meeting,” giving the patient the comfort of knowing they have another opportunity to speak, and to form questions, once the edge of panic subsides.

		Success of the Oncology Nurse Navigation at Fox Chase Cancer Center

	↓ fear and anxiety at first appointment

Throughout the care continuum, Daugherty advised her colleagues, “maintain availability”—be reachable for questions such as the meaning and consequences of genetic testing. For BRCA mutation— positive patients, she added, nurses should provide information about poly (ADP-ribose) polymerase (PARP) and the promise of PARP inhibitors, which are undergoing clinical trials in individuals with BRCA1/BRCA2 mutations.

Cancer centers are beginning to establish oncology nurse navigator programs with integrated processes for assessment, identification, referral, education, care, and support for patients whose gynecologic cancers may be genetically-based.

Integrating Genetics and Genomics in GYN Patient Navigation

		Alicia Bitterice is with the Taussig Cancer Center, Cleveland Clinic, and

		Polly Mazanec is Assistant Professor at the Frances Payne Bolton School

	Chemotherapy-induced peripheral neuropathy (CIPN) is a common and potentially dose-limiting side effect of many chemotherapy drugs. The incidence of CIPN in the cancer population depends upon the agent used to treat but has been estimated to be as high as 90% in patients treated with any neurotoxic chemotherapeutic agents.

 The pain and loss of function that result from CIPN are debilitating and can impact all domains of quality of life.

	The mechanism by which chemotherapy damages nerves is not well understood and may vary depending upon the offending agent.

 It has been proposed that “chemotherapy may first damage sensory axons that, in turn, cause the destruction of other axons and myelin sheaths.”

 Damage to large fibers results in loss of proprioception, deep tendon reflexes, muscle sheath, and diminished or absent sharp/ dull and two-point discrimination. Damage to small fibers results in sensory changes causing numbness and tingling, burning, decreased pinprick sensation, and temperature change.

	Typically, peripheral neuropathy begins in the toes, moves to the feet and then up the legs as it progresses; this can also occur in the fingers, spreading to the hands and arms. This distribution is referred to as a “stocking-glove pattern.”

 Autonomic symptoms such as postural hypotension and constipation are also possible; CIPN is usually, although not always, reversible with the cessation of treatment.

	The wide variety of symptoms experienced by cancer patients with CIPN means that this symptom has the potential to greatly affect all domains of quality of life. Physically, the sensory and motor deficits associated with CIPN can limit a person’s functional capabilities. Interviews with 14 cancer patients with a variety of malignancies receiving neurotoxic chemotherapy found that 57% reported impairment in carrying out activities of daily living.

 The patients reported impairments such as inability to get in and out of the bathtub due to muscle weakness, inability to hold a pen or pencil due to loss of manual dexterity, and inability to drive because they were unable to feel their feet on the pedals.

	It is important to note that patients may fear discussing their physical symptoms with their clinicians for fear that their treatment will be stopped.

 However, if the sensory and motor deficits are not identified and chemotherapy dosing or drugs not adjusted accordingly, the neuropathy could continue to progress and the impairment could become even more disabling and may not be reversible. In addition to limiting function, CIPN is associated with pain and sensory discomforts, disrupted sleep, and fatigue.

	The symptoms associated with CIPN can impact the psychological, social, and spiritual domains as well. Treatment-related neuropathy can be a constant reminder of having cancer and add to distress, anxiety, and depression. The inability to walk or stand for long periods of time or the loss of fine motor skills leaves those with CIPN unable to participate in activities that are important to them, like sports and hobbies, leading to feelings of social isolation.

 The impairment from the neuropathy can also have a major impact on work and family roles. CIPN also can result in spiritual distress. Patients have reported feelings of hopelessness as a result of the pain of CIPN.

	The nurse’s role in helping patients to manage CIPN is to first assess all patients being treated with potentially neurotoxic chemotherapeutic agents for signs and symptoms of peripheral neuropathy at every visit.

 It is important to note that patients may not identify or describe CIPN as painful, and so, when asking about symptoms, the nurse should ask about any new numbness, tingling, or uncomfortable sensations. If the patient endorses any of these symptoms, further assessment is warranted and should include a neurologic assessment and a falls-risk assessment.

	Pharmacologic management of CIPN has been shown to help with neuropathic pain and numbness and tingling, but some of the functional impairment is difficult to recover once it has occurred. Medications commonly used include anticonvulsants, such as gabapentin, tricyclic antidepressants including nortriptyline, and selective serotonin norepinephrine reuptake inhibitors (eg, duloxetine, venlafaxine

	Nonpharmacologic approaches that the nurse may suggest include referrals to other team members. Trained PT and OT professionals can provide strategies to improve functionality, and assistive devices such as canes and orthotics may improve balance and prevent falls.

 The nurse is responsible to educate the patient and family about the importance of safety and preventing injury. The sensory and motor losses put the patient at high risk for falls, burns, or wounds that may not even be noticed. Attention to foot and hand care is essential.

	Psychological counseling and social work support may help with the psychological impact and the work/role changes that may occur as a result of the impairment and pain. In addition, referral to chaplaincy may assist in addressing spiritual distress that may be associated with the challenges of living with CIPN.

				Boland BA, Sherry V, Polomano RC. Chemotherapy induced peripheral neuropathy in cancer survivors. 

http://www.cancernetwork.com/nurses/content/article/10165/1523565

				Biedrzycki BA. Peripheral neuropathy. In Brown CG, ed. 

. Pittsburgh, PA: Oncology Nursing Society; 2010:405-421.

				Tofthagen C, Visovsky CM, Hopgood R. Chemotherapy-induced peripheral neuropathy: an algorithm to guide nursing management.

				Visovsky C, Collins M, Abbott L, Aschenbrenner J, Hart C. Putting evidence into practice: evidence-based interventions for chemotherapy-induced peripheral neuropathy. 

				Tofthagen C. Patient perceptions associated with chemotherapy-induced peripheral neuropathy. 

				Bakitas MA. Background noise: the experience of chemotherapy-induced peripheral neuropathy. 

Chemotherapy-induced peripheral neuropathy is a common side effect in patients with cancer and nurses are essential to helping patients to manage this condition.

Managing Chemotherapy-Induced Peripheral Neuropathy

		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

The “Bench to Bedside Lecture” delivered at this year’s Oncology Nursing Society Congress was on the topic of obesity and cancer risk. It is no surprise that increasing rates of obesity are linked to increasing cancer incidence, but what is interesting is just how bad things are now, and how bad they are predicted to become in the years ahead.

The National Cancer Institute (NCI) estimates that 69% of adults in the United States are overweight or obese (defined as a body mass index [BMI] >25). That means that 7 of every 10 adults now exceed healthy weight targets. And children are catching up: 3 in 10 are overweight or obese. If these trends continue, there will be a half million additional cases of cancer in the United States by 2030. That’s only 17 years from now, so many of us will be around to see if this in fact occurs, and if it does, we’ll have many more patients with cancer to care for.

So what’s behind the association of obesity and the increased risk of certain types of cancers, such as endometrial, colorectal, esophageal, pancreatic, renal, and postmenopausal breast cancers? Several possible mechanisms have been suggested. Fat tissue, for instance, produces excess amounts of estrogen, and high levels of estrogen have been associated with the risk of breast and endometrial cancers.

Obese people often have increased levels of insulin and insulin-like growth factor-1 in their blood, also known as insulin resistance, which may promote cancer development. Fat cells produce hormones (adipokines) that may stimulate cancer cell growth. The hormone leptin, which is more abundant in obese people, appears to promote cell proliferation, whereas adiponectin, which is less abundant in obese people, may have antiproliferative effects. Fat cells may also have direct and indirect effects on other tumor growth regulators, including mTOR and AMP-activated protein kinase.

Other possible mechanisms include oxidative stress, chronic low-level inflammation, altered immune responses, and effects on the nuclear factor kappa beta system.

If every adult reduced his or her BMI by just 1% (equivalent to a weight loss of about 2 pounds), for an adult of average weight, this would prevent the increase in the number of cancer cases and actually result in the avoidance of about 100,000 new cases of cancer each year in the years to come. Further reduction in cancer incidence would occur if obesity in our nation was reduced.

Several NCI Research-tested Intervention Programs (

) provide the evidence that interventions, such as awareness building and behavior modification, can increase healthier eating and promote weight loss. The most recent program added to the site in March 2013 is the Complete Health Improvement Program, a group lifestyle modification course for adults in community and workplace settings. An interesting aspect of this program is that participants are highly encouraged to enroll in the program with their spouses/partners. Having a buddy is a well-known weight loss strategy, and engaging the entire family in healthy eating behaviors and physical activity is even better.

Many people think that tobacco is the factor that most contributes to the risk of developing cancer; however, the number one factor is diet and obesity (tobacco accounts for a 30% risk while diet/obesity accounts for a 35% risk of cancer). The obvious conclusion is that the public should be encouraged to maintain a healthy weight, or if overweight, to lose weight.

Observational studies have found that people who have a lower weight gain during adulthood have a lower risk of colon and endometrial cancer, as well as postmenopausal breast cancer. However, many of these studies have not been able to evaluate whether the weight loss was intentional or not. Stronger evidence comes from studies of patients who have undergone bariatric surgery; these patients have lower rates of obesity-related cancers than obese people who did not have the surgery.

Once again, nurses are at the forefront of cancer prevention and have numerous opportunities to promote healthy behaviors at home, in the workplace, and in the community.

Nurse's Notes

It is no surprise that increasing rates of obesity are linked to increasing cancer incidence, but what is interesting is just how bad things are now, and how bad they are predicted to become in the years ahead.

A Weighty Issue: Obesity and Cancer Risk

Creating more opportunities for patients to report their symptoms and treatment experiences is essential to providing patient-centered care, said Donna L. Berry, PhD, RN, AOCN, FAAN, addressing a packed hall of her colleagues at the Oncology Nursing Society Annual Congress.

“We’ve found that providers don’t always hear what is important to the patient,” said Berry, who described some of the research she and others have conducted to explore new ways to improve patient— provider communication. Berry, this year’s Mara Mogensen Flaherty Lecturer, directs the Phyllis F. Cantor Center for Research in Nursing and Patient Care Services at the Dana-Farber Cancer Institute in Boston, Massachusetts. The Flaherty lecture is an annual presentation at the ONS Congress to spotlight best practices in managing the psychosocial aspects of cancer.

Berry explained that clinicians need to create an environment where cancer patients—as well as patients with other conditions&mdash;can feel comfortable expressing their concerns and are empowered to engage in self-care. She said that making sure that patients receive&mdash;and comprehend&mdash;accurate information about their disease is paramount, but just as important is understanding what personal factors each patient brings to the table when deciding on treatment. Such factors typically include the patient’s age, anxiety level, influence of others in their decision-making process, and worries over quality of life (QoL) following a cancer diagnosis.

A more thorough understanding of these personal factors would help clinicians to target their education to match each patient’s priorities, said Berry. “We can’t mass-produce something that’s customized to each patient on a piece of paper or in a binder,” said Berry.

“We provide informed consent, we provide patient education, we provide reams of material, but do we help patients navigate these decisions? How do we prepare them, and how do we honor the part of their lives that is not with us in the clinic?” asked Berry.

To help meet this challenge, Berry and colleagues developed the “Personal Patient Profile—Prostate” (P3P), drawing on their previous research and interviews with a group of patients diagnosed with localized prostate cancer. P3P was designed to spontaneously generate tailored and customized education and coaching for patients, based on their individual responses to an electronic questionnaire focused on what and who is influencing their treatment decisions.

The intervention also allowed patients to choose the type of tailored education they believed would be most beneficial, including coaching on how to tell their doctor what is most important to them and to discuss such topics as erectile dysfunction and bowel problems. Berry noted that the coaching videos were customized according to both race and age, so that patients could see people like themselves engaging in these discussions with their providers. Other topics for coaching support, which utilized various combinations of text, video, and graphics, included understanding statistics, current symptoms, and informational websites.

Men who received the P3P intervention reported significantly less conflict in making their treatment decisions, Berry said. In addition, men who felt more prepared for their treatment decision visited their physician more often and had read literature provided by the clinic.

Helping patients to make informed decisions about treatment is an important first step, but challenges remain when treatment begins. “It’s quite an understatement to say that patients need support during treatment,” Berry continued. “The patient’s experience, their symptoms, and their quality-of-life concerns are incredibly important to the safety and deployment of treatment. We can’t safely treat our patients unless we hear what the effect of their treatment is on each one.”

Berry, in her prior role mentoring clinicians and students at the University of Washington, worked with nurses at the UW Medical Center in Seattle to develop another electronic tool, the “Electronic Self-Report Assessment for Cancer (ESRA-C)”.

“Together, we decided that we needed to improve our ability to capture the patient’s experience, and it had to be timely, it had to be accurate, and it had to be efficient.”

As part of the initial ESRA-C, patients completed a series of symptom questionnaires, generating a color-coded report allowing clinicians to see clearly those areas marked in red where patients were experiencing the most difficulty.

The randomized trial found that patient symptoms and QoL concerns were addressed significantly more often when the ESRA-C summary was available to clinicians. Researchers also looked at which symptoms tended to get more attention, and Berry reported that discussions of nausea and pain were more often initiated by clinicians, whereas discussions of fatigue and sexual concerns more often by the patient.

Creating more opportunities for patients to report their symptoms and treatment experiences is essential to providing patient-centered care.

June 2013