Associate Professor in the Department of Community-Public Health

Although we as healthcare providers want to be cautious and not provide a sense of false hope, we can also acknowledge that for individuals who are deeply religious and spiritual, terminal illness that results in death may not be viewed as negative. Whatever our own beliefs, such an acknowledgment can build cross-cultural bridges of trust. And research suggests that it may indeed help ease the worry and suffering of patients and families touched by such a frightening experience.

A cancer diagnosis comes with psychological distress. Patients worry about disruptions in work and social roles, have body image concerns, and fear progressively worsening disease associated with pain, weight loss, and eventual death. When psychological distress is high, both patients and family members have a decreased ability to communicate needs for information and support and to process information received about the illness.

Patients with cancer and their family members often rely on their spirituality and religious beliefs to overcome fears and anxieties, for strength to endure prescribed treatment, and to find meaning in the experience. Although it is generally accepted that spirituality and religious beliefs are important to the cancer experience, little is known of how they could be used to positively influence adherence to treatment and improve outcomes.

In our research conducted with 31 African American cancer survivors, a frequently expressed religious belief (n = 11) was that God had the ability to cure cancer. This belief and hope for continued life motivated participants to seek treatment in spite of advanced illness and even when healthcare providers had delivered news that their illness was terminal.

A closely related religious belief was that God was in control over life and death (n = 11). For these survivors, God was given credit for whether they survived cancer, for providing healthcare professionals with knowledge to treat them, for sending the social support they needed, and for giving them the strength to overcome negative comments and stories of others who had died from cancer.

The belief that God had a plan for their lives (n = 8) enabled survivors to accept the diagnosis and face it as they would any other stressful life event. For these survivors, the cancer served some purpose in their lives or could have been God’s way of communicating to them that they needed to make a change. And, there was the belief that if life were to end in this world, then God must want them in heaven, and that was also a good outcome.

Survivors also discussed the positive influences of singing religious songs and reading Bible verses. Survivors used them as a form of communication with God, a way of requesting help, and expressing gratitude. Hymns and Bible verses were a distraction from depressed moods and physical pain.

Although we cannot assume that patients with cancer are monolithic, a shared experience among a majority of US populations is the certainty that God exists and that religion is very important to their lives.

 Among African American populations, religion is especially important. Scholars who have traced and examined the religious expressions of African Americans report a belief that God is an all-powerful being, a protector capable of delivering those who believe in Him from the pain and suffering that come with this worldly existence.

 The pressing question for healthcare providers is how these research findings might be useful to support patients and family members through a cancer diagnosis and treatment. One suggestion would be to encourage the expression of religious beliefs during patient encounters and incorporate religious beliefs into cancer care.

For example, to decrease patients’ and family members’ anxieties and fear of death, remind patients to use their spirituality, as this could be calming, enabling them to better process the information we are giving them. Encourage the use of a favorite religious song or Bible verse to decrease fear and anxiety. Asking about spirituality might be a nonthreatening and culturally sensitive way to begin conversations related to the psychological distress associated with a cancer diagnosis. The 23rd Psalm is a favored and widely used part of scripture, as are the hymns “Amazing Grace” and “I Will Trust in the Lord.”

We do not need to have similar beliefs to provide patients and families with spiritual support. Our patients want us to acknowledge and understand that God is real, tangible, and central to every aspect of their lives. Being respectful of this can assist patients and their family members in overcoming their fears and anxieties and facilitating a sense of trust and hopefulness, as we attempt to provide optimal cancer care.

Hamilton JB, Galbraith KV, Best NC, et al. African American cancer survivors’ use of religious beliefs to positively influence the utilization of cancer care. 

Pew Research Center. Pew Forum on Religion & Public Life. A Religious Portrait of African-Americans. 2009. http://www.pewforum.org/2009/01/30/a-religious-portrait-of-african-americans. Accessed May 25, 2016.

 Suffering and Evil in Black Theology. New York, NY: Continuum; 1999.

Articles

Partner Perspectives

Although we as healthcare providers want to be cautious and not provide a sense of false hope, we can also acknowledge that for individuals who are deeply religious and spiritual, terminal illness that results in death may not be viewed as negative.

Using Spirituality and Religious Beliefs to Positively Influence Cancer Care

Healthcare practitioners know all too well how technology has transformed their workplace. These changes can be a bane or a blessing—sometimes both&mdash;as many nurses and other clinicians will attest.

On the one hand, mobile symptom-monitoring apps, health trackers, social media, and specialized websites can empower patients with cancer to better manage their disease and at the same time, help to connect them with a supportive network of advocates, patients, survivors, and caregivers on the same journey.

On the other hand, some experts and many patients and family members worry that all this technology can sometimes be dehumanizing, hin&shy;dering that all-important clinician—patient human interaction. In 

editor-in-chief Lisa Schulmeister, MN, RN, ACNS-BC, FAAN, writes about this need to pro&shy;vide “high-touch” care in a high-tech world, noting that the realities of high-tech care, which frequently requires practitioners to focus their attention on laptops or machines, can leave them little time to focus on the patient.

Whatever your particular take on how this tech&shy;nology has impacted oncology nursing practice, it is here to stay. Healthcare systems and tech giants like Apple are enlisting technology and clinical ex&shy;perts to help them develop tech-based solutions to address healthcare delivery challenges and improve the patient experience. And, Microsoft is now col&shy;laborating with scientists to analyze large numbers of internet queries and search patterns to identify early signals of a subsequent cancer diagnosis. In their recent study of such indicators in pancreatic cancer, investigators were able to identify 5% to 15% of cases of adenocarcinoma, with low rates of false-positives.

The good news is, oncology nurses—ever the problem-solvers looking to advance patient care&mdash;are coming up with and deploying their own 

At the recent 2016 Annual Meeting of the Ameri&shy;can Society of Clinical Oncology (ASCO), research&shy;ers shared impressive results from a pilot study conducted in France of a lung cancer symptom-reporting app known as MoovCare. MoovCare resulted in a 7-month longer survival for those who used the app when compared with controls (19 vs 12 months, respectively). Additionally, 75% of the patients followed through MoovCare were still alive at 1 year versus 49% with standard procedures.

MoovCare is a software application that patients or their caregiver use to report symptoms. The algorithm analyzes the information for signals of potential relapse or complications and, if necessary, notifies the oncology care provider via email. The app can be accessed on mobile and desktop devices.

The system made a difference for patients because it resulted in early detection of dangerous conditions or recurrences, resulting in healthier in&shy;dividuals who were better able to undergo optimal therapy and earlier supportive care that improved quality of life, reported lead study author Fabrice Denis, MD, PhD, at an ASCO press conference.

Having these tools available as we try to deliver better care will be very important, said Patricia Ganz, MD, of UCLA’s Jonsson Comprehensive Cancer Center and ASCO Expert in breast cancer, who moderated the press panel.

 “As someone who has been doing quali&shy;ty-of-life patient-reported outcomes for 35 years, systematically asking patients spe&shy;cific questions and asking them to respond is very different than asking them, ‘How are you today? Do you have any problems?’ This kind of [systematic] monitoring, however you do it, is good. We need to get that information from patients, so we can inter&shy;vene early.” Ganz said.

She added that this is the goal of tools be&shy;ing advanced in the United States, such as the 

Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE)

, an electronic-based system for patient self-reporting. “We’re trying to restructure how we deliver care so that we can be more responsive to these kinds of changes," and with these tools, patients can report their symptoms on a regular basis.

However, Ganz stressed, making it easier for patients to report their symptoms is only part of the equation, and here is where nurses play a pivotal role.

“There have actually been many experiments similar to [the MoovCare app] in the United States, and when the feedback information comes just to the doctor, there’s not much action about it. You need someone in the office practice, whether it’s a nurse or some other person, who is actually looking at the data as they come in, and trigger a response.”

Another ASCO spokesperson, Gregory A. Mas&shy;ters, MD, of the Christiana Care Health System, added that while the MoovCare system presents “one way to engage patients and allow them to take a more active role in their care … it is certainly not the only way,” for example, to monitor patients who are more infirmed or who may not be comfortable with a cell phone app. "If you completely switched over to that, you might lose some of those patients, so we have to figure out how to integrate the new technology.”

As practitioners know all too well, patient use of wearable health technology (“wearables”) to track their health data has grown tremendously. The consulting firm Accenture reported that the number of US consumers using wearables and mobile health&shy;care apps has doubled from 16% in 2014 to 33% today, with the majority of consumers (77%) and doctors (85%) reporting that using wearables helps patients to engage in their own health.

“Through wearable devices, Wi-Fi—enabled home health devices, and other innovations, nurses will be able to help patients to be more proactive and feel empowered to maintain and improve their healthcare,” noted Jason J. Fratzke, RN, MSN, chief nursing informatics officer for the Mayo Clinic in Rochester, Minnesota.

Wearable technology also has a role in cancer clinical trials, with wearable activity monitors (WAMs) increasingly being used to monitor patient physical activity, behavior, and sleep in survivors and patients who have a relatively good prognosis.

In a small pilot study reported at the 2016 ASCO Annual Meeting, researchers are looking at the impact of WAMs, using the Fitbit Charge HR, in assessing patient well-being between office visits.

, researcher Arvind Shinde, MD, a medical oncology and palliative care practitioner at Cedars-Sinai Medical Center in Los Angeles, noted that he has found that, “we really don’t have a good under&shy;standing of how patients are doing outside the four walls of our clinic.”

He explained that while clinicians try to assess performance status during clinic visits, “for a vari&shy;ety of reasons, these assessments are incomplete and biased … patients may not remember how they’ve been doing over the past week, or they may want to convince themselves and their physicians that they’re doing better than they are.”

The study is ongoing, but even early on, Shinde said that investigators are finding that “almost universally, patients are able to wear the trackers continuously and charge them, and most patients want their oncologists to have this information and feel like it will help make better decisions.”

 He hopes that with this technology, clinicians will be able to better understand how patients are doing between visits and then “intervene if something isn’t going well in a way that’s beneficial to the patient and less costly to the system:

“It’s all about patient-centric assessments and patient-centric decision making … There’s great value in learning how to use this technology—we just have to learn how to use it. The technology is rapidly progressing, so it’s a great opportunity.”

Paparrizos J, White RW, Horvitz E. Screening for pancreatic adenocarcinomas using signals form web search logs: feasibility study and results [published online before print June 7, 2016]. 

Denis F, Lethrosne C, Pourel N, et al. Overall survival in patients with lung cancer using a web-application-guided follow-up compared to standard modalities: results of phase III randomized trial. 

. “Adoption of Health Apps, Wearable Devices Grows.” 

. “Mobile Apps Help Boost Efficiency for Nurses.” 

Gresham GK, Piantadosi S, Drye L, et al. Applications of wearable activity (WAM) in cancer clinical trials (CT): a review of the literature. 

Shinde AM, Gresham GK, Hendifar AE, et al. Biosensors to assess performance status in cancer (BioAPS Study). 

Cover Story

Healthcare practitioners know all too well how technology has transformed their workplace. These changes can be a bane or a blessing&mdash;sometimes both&mdash;as many nurses and other clinicians will attest.

Tech Takeover: New Tools and Resources to Improve Cancer Care

As nurses, we’re skilled at innovating. We have to be. The nature of our work means we often have to find new ways to help our patients. From new teach&shy;ing methods to time-saving wound care tech&shy;niques, every nurse has, at some point in his or her career, needed to think up something on the fly for the benefit of a patient.

This is innovation in action, and it's at the heart of the MakerNurse movement. Started in 2013, MakerNurse focuses on identifying and fostering nursing innovation in hospitals across the United States.

Every day, nurses and technology specialists are working to improve cancer outcomes and make both the treatment and quality of life better for oncology patients. These innovators are using technology to develop products and services that guide cancer treatment, educate patients and families, and promote well-being and a positive outlook.

While these individuals come from different educational and professional backgrounds, they are blazing a trail in the treatment of cancer. They embody the spirit of the MakerNurse movement, using creativity to develop techno&shy;logical solutions in the fight against cancer.

It’s no secret that oncol&shy;ogy care is complicated. Patients face a laby&shy;rinth of personal and financial challenges during their treatment. Treatment teams want to provide the best evi&shy;dence-based care possi&shy;ble, but are challenged by the staggering amount of available information and trouble&shy;some reimbursement systems.

Carevive Systems, a company cofounded by Carrie Stricker, PhD, RN and Madelyn Herzfeld, BSN, RN, was formed in response to the need to provide more support for patients, families, and care teams.

The idea for Carevive started in 2007 after Stricker noticed a striking need for tools to help navigate the complex world of cancer care. With over 20 years of clinical practice and nursing research experience, Stricker had repeatedly witnessed her own patients’ difficulties in nav&shy;igating through the healthcare landscape. She was inspired by the seminal Institute of Medicine 2005 report, 

to help address the reality that patients who weren't receiving active treatment were "left behind" by the system.

In response, Stricker started to develop care plans to serve people transitioning from treat&shy;ment to survivorship, but making these care plans was extremely time consuming and inef&shy;ficient. Eventually, she realized that emerging technology offered the perfect opportunity to streamline the process. In collaboration with Herzfeld, Carevive was formed in 2013 (origi&shy;nally as On Q Health) to help develop care plans for all phases of the cancer experience, based on current research and patient priorities. It’s currently being used in 30 healthcare systems across the country.

Stricker explained that Carevive’s mission is to “provide clinical workflow tools and patient engagement solutions to help cancer centers in providing comprehensive, value-based care to indi&shy;viduals and families with cancer. The goal is to sup&shy;port patients, families, and survivors in navigating their cancer experiences with optimal quality of life, and as active members of the care team.”

To that end, Carevive's cloud-based technol&shy;ogy consumes and analyzes EMR and other clinical data sources, such as tumor registry data, along with patient-reported health data, to support the care team in planning patients' treatment, managing their symptoms, and sup&shy;porting their survivorship needs. The aggregated data gathered in this process also are used to provide insight into the real-world ex&shy;periences of patients with cancer, enabling pre&shy;dictive analytics and to continuously improve outcomes.

Based on the information reported, patients receive a personalized treatment plan for managing their personal symptoms. These patient-specific plans are focused on such areas as pa&shy;tient priorities, diagnostic data, evidence-based cancer treatment pathways, possible side effects, care and outcome goals, eligibility for clinical trials, and other resources.

Clinically, providers can use the reported in&shy;formation to prioritize concerns during patient visits, encouraging better communication and collaboration between the healthcare team and the patient. The healthcare team can also use reported patient information to map out trends in symptoms, side effects, and patient outcomes. With so much of oncology care funding and reimbursement driven by census, statistics regarding patient treatment at various facilities can help drive cancer costs in a more benefi&shy;cial direction for all.

The diagnosis and treat&shy;ment of cancer might be the most emotionally devastating experience of a person’s life, but it’s not just the patient who is affected. Cancer reaches out, touching the lives of family members, friends, and even co&shy;workers. Just as an evidenced-based treatment plan is essential in the fight against cancer, so, too, is a plan for the care and support of a per&shy;son’s mental and emotional health. That’s where CanSurround comes in.

CanSurround is the brainchild of cofounders Meg Maley, BSN, RN, Jill Teixeira, MSN, RN, and John Brilliant. Both nurses had already worked in oncology for years; they collaborated together to shape an oncology home health&shy;care company, and had both consulted with WellDoc, a technology company that created software for use in a variety of medical special&shy;ties. Both women saw how the mind’s journey through the cancer experience is often—but not always&mdash;neglected.

As Maley explained, “we were very interested in the emotional ride … we wanted to pull togeth&shy;er features that were researched-based and put them on a platform whereby people could access them 24/7, confidentially and on their own terms, to help themselves manage the distress they’re feeling and move them toward resilience.”

The pilot CanSurround program launched in 2015, and the company is currently working to commercialize with cancer centers across the country. The program is available online and as a mobile app for anyone affected by cancer.

CanSurround estimates that for every 1 person diagnosed with cancer, at least 5 others are affected by the diagnosis. Patients, family, friends, and coworkers can all benefit from the program, which is focused on creating emotion&shy;al well-being and a positive, mindful approach to cancer treatment.

The program takes a personalized approach to building resilience and reducing stress by utilizing tools and resources proven to help develop a more positive mindset. This is done through education and inspiration. Users have access to a wealth of evidence-based clinical information and cancer resources, including educational materials and checklists for differ&shy;ent phases of care.

 Features also include an online journal to record positive thoughts, photos and memories, and multimedia experiences like guided imag&shy;ery, focused breathing, and meditation exercises. Through a partnership with Byron Katie, a thought inquiry program has been developed to help people identify and examine negative, stressful thoughts, one thought at a time, to promote a more positive mindset.

Another option invites users of CanSurround to join a group, allowing people to support and comfort each other in a community that understands the cancer experience intimately. Once subscribed, users will receive emails from the CanSurround team every 3 days with specially selected informational articles and messages to educate, inspire, and inform.

The idea for Sickweather was born when co&shy;founder, CEO, and president Graham Dodge became a parent. He was concerned after discovering that there was no real-time in&shy;formation about the spread of illness where he lived. During this time, another company cofounder was caring for a parent with cancer and was also worried by the lack of information about illnesses in his community.

Both men were inspired to figure out how illnesses could be tracked, so that they and the public could take more informed steps to protect against getting sick. As Dodge noted, “We see this as being something for anyone who is a caretaker for anyone else—whether its parents with young children or anybody caring for someone having chemo. It’s (for) whoever is in the position of caring for somebody else and making decisions for them.”

Although not developed specifically for pa&shy;tients with cancer, Sickweather provides invalu&shy;able information about the occurrence of illness in a person’s surrounding community. Actively avoiding areas where sickness is present is critical in oncology, because cancer and cancer treatment methods can leave a person with a severely weakened immune system.

The knowledge provided by the program can help those affected by cancer and their caregiv&shy;ers limit their exposure to illnesses that can be devastating to already fragile patients.

Sickweather is available online or as a mo&shy;bile app. The program uses preset algorithms to scan social media networks like Facebook and Twitter for illness by using keywords. Data are also collected from crowdsourced inputs.

 Currently, the app is tracking reports in En&shy;glish only, but includes all regions around the world where English is the primary language. Once the resources are available, the company hopes to start translating reports from other languages.

When an illness has been identified, the information about the location of the report is entered into a database, which then shows that information on a map—down to street level and in real time. Individuals can also enter illness information into the system independently. The program collects about 6 million separate re&shy;ports every month.

Users can see where sickness outbreaks were occurring and when they are occurring. People

also can receive illness alerts if they subscribe to Sickweather, making it possible for them to consciously avoid those areas where illness is occurring.

These are just three examples of innovation in action—inspired by healthcare providers and technology professionals working together to create new software products that benefit oncol&shy;ogy patients and others. With these tools, it is now possible to reach more patients and health&shy;care providers. The spirit of the MakerNurse movement is at the heart of each of these inno&shy;vations, making the journey though the cancer experience more positive and less stressful.

 A community of inventive nurses creating solutions to improve patient care every day, providing tools, platforms, and training to help MakerNurses create the next genera&shy;tion of health technology.

 Provides a range of tools to support oncology practitioners in their efforts to improve patient care and outcomes, including Electronic Patient-Reported Outcomes (e-PRO), Clinical Trial Accrual, Initial Treatment Plans, Dis&shy;tress/Symptom Management Plans, and Survivorship Care Plans.

 Focuses on reducing stress, building resil&shy;ience, and enhancing well-being for individ&shy;uals affected by cancer, with such features as a multimedia journal, mind—body exercises, and a circle of support, all with an eye toward providing individuals with a healing space accessible anytime, anywhere. For a limited time, patients and caregivers are invited to sign up at CanSurround as early partici&shy;pants, free of charge.

 This sickness forecasting and mapping tool can be especially useful to patients with compromised immune systems due to cancer or its treatment, alerting them to the risk of contagious illness in their area. The program is free; anyone can join, anytime, to start tracking illnesses in their area.

Nurse-Designed Software Innovations Are Changing the Cancer Experience

The new generation of drugs that has emerged as part of antiemetic cocktails has demonstrated greater success in preventing and controlling chemotherapy-induced nausea and vomiting (CINV), but the symptoms—particularly nausea&mdash;still present significant obstacles in anticancer therapy, and the ultimate goal of prevention in all patients has yet to be attained.

CINV occurs following treatment with many different kinds of chemotherapeutic agents, but it was the introduction of cisplatin-based therapy in the late 1970s that dramatically increased the incidence of this toxicity and thrust it into the spotlight. Clinicians have since developed guidelines for the management of CINV, which introduced a classification system for cytotoxic drugs based on their emetogenic potential.

During the past 25 years, an improved understanding of the molecular pathways involved in the pathophysiology of CINV has translated into major advancements in preventive treatment, including FDA approval of two new drugs in the past 18 months. Nevertheless, these pathways are highly complex, involving a myriad of different neurotransmitters and receptors located centrally in the brain and peripherally in a number of tissues and organs.

Cisplatin falls into the category of highly emetogenic. The percentage of patients with acute emesis caused by single-agent cisplatin in the absence of preventive therapy is more than 90%. Chemotherapy drugs can also be classed as having moderate (>30%-90%), low (10%-30%), or minimal (0-<10%) emetogenic potential.

The emetogenic potential varies, not only according to the type of drug, but also in response to other factors, such as the dose administered and the intravenous infusion rate. What’s more, drugs that are only moderately emetogenic when administered as a single agent may become highly emetogenic when used in combination, with a prime example being the combination of epirubicin and cyclophosphamide.

Nausea and vomiting are not restricted to chemotherapy and can be caused by other types of anticancer drugs; however, until recently this was largely overlooked.

Numerous anticancer agents including targeted therapies and immunotherapies are now being assessed for their emetogenic potential.

Initially, corticosteroids such as dexamethasone and dopamine receptor antagonists, (including metoclopramide and haloperidol) formed the basis of preventive therapy for CINV; however, these proved to have limited effectiveness in the setting of more highly emetogenic chemotherapy (HEC). With the introduction and widespread adoption of cisplatin-based chemotherapy, this became an increasingly important unmet need.

The discovery of key receptors involved in the pathways central to the pathophysiology of CINV prompted development of antagonists to block their effects. A major landmark came in the early 1990s with the approval of the first serotonin receptor antagonist, ondansetron, which was rapidly incorporated into routine clinical practice after demonstrating superior efficacy and safety to what was then the standard of care regimen of metoclopramide and dexamethasone.

In 1997, odansetron was joined by two additional serotonin receptor antagonists, granisetron and dolasetron. The three first-generation drugs have equivalent efficacy in preventing acute CINV at their recommended doses when used in combination with dexamethasone, but they have limited efficacy against delayed CINV.

They also display comparable safety profiles, with headache, constipation, and mild diarrhea the most commonly reported adverse events.

Although these events are mostly short-lived and clinically insignificant, there is a potential for more serious cardiac toxicity.

Serotonin receptor antagonists remain a central component of preventive treatment for acute CINV, although the first-generation drugs have mostly been replaced by a newer drug, palonosetron. First approved in an intravenous formulation in 2003, followed later by an oral formulation, palonosetron is more potent than the first-generation drugs, predominantly as a result of its higher binding affinity for the receptor and its significantly longer half-life. Palonosetron also has the advantage of not being associated with cardiac toxicity.

Managing Delayed Chemotherapy-Induced Nausea and Vomiting

Based on differences in the timing of onset, CINV has been classified into categories:

: occurring within 24 hours of the start of chemotherapy

: occurring 24 hours to several days postchemotherapy

: occurring before a subsequent cycle of chemotherapy (this is a learned response often triggered by a fear of CINV or previous experience)

: both occurring despite preventive treatment

Although serotonin receptor antagonists revolutionized the treatment of acute CINV, many patients experience delayed CINV, and these drugs were relatively ineffective in preventing that outcome. Palonosetron is the only member of this drug class to have demonstrated efficacy in both the acute and delayed settings in patients undergoing moderately emetogenic chemotherapy (MEC).

For the most part, however, efforts to better manage delayed CINV have focused on the development of drugs targeting the NK1 receptor, since its substance P—mediated effects seem to be particularly important in this later time period. Furthermore, studies suggest that the efficacy of palonosetron in the delayed setting may result from its ability to inhibit serotonin and NK1 receptor crosstalk.

In the same year that palonosetron was approved, the first NK1 receptor antagonist, aprepitant, was also brought to the market. An intravenous prodrug formulation, fosaprepitant, has also been approved, offering a potential option for patients who cannot tolerate oral administration of antiemetic therapy.

A meta-analysis of 17 trials involving more than 8500 patients clearly demonstrated that the addition of an NK1 receptor antagonist to the regimen of a serotonin receptor antagonist and dexamethasone provided superior out-comes, most importantly improving the complete response rate to more than 70%. The benefit was particularly noticeable in patients receiving HEC.

Thus, the standard of care for CINV evolved, with serotonin receptor antagonists in combination with a corticosteroid (most commonly dexamethasone) forming the backbone of antiemetic therapy for patients undergoing MEC, and addition of an NK1 receptor antagonist for patients undergoing HEC.

Guideline recommendations have been developed by various organizations, including the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO), and the appropriate use of these drugs according to these recommendations forms the cornerstone of CINV management.

The development of antiemetics has been ongoing, and several new drugs have emerged in recent years that offer improvements to the standard of care, particularly in the management of delayed CINV and in patients undergoing HEC.

Netupitant is a novel NK1 receptor antagonist, designed with improved pharmacokinetic properties including a longer half-life. It was developed by Eisai, the same company that makes palonosetron, specifically for use in a single oral capsule that combines fixed doses of the two drugs. NEPA (Akynzeo) comprises 300 mg netupitant and 0.5 mg palonosetron to simultaneously target two key pathways of CINV and, it is hoped, to simplify treatment and improve adherence to guideline recommendations.

The FDA approved NEPA in October 2014 on the basis of several randomized, double-blind clinical trials that demonstrated superior complete response rates for NEPA compared with oral palonosetron, both in combination with dexamethasone, in patients receiving MEC and HEC. Complete response was defined as no vomiting and no need for rescue medication.

NEPA significantly improved the prevention of CINV across both the acute and delayed period postchemotherapy for multiple cycles of chemotherapy. Analysis of a subgroup of patients receiving cisplatin or an anthracycline plus cyclophosphamide in two of the clinical trials suggested that NEPA might also help to prevent nausea, which has typically proved much more challenging to treat than vomiting.

In one of the pivotal trials, which enrolled patients with HEC, NEPA/dexamethasone was also compared with a combination of oral aprepitant plus palonosetron and dexamethasone, and the two regimens appeared to have similar efficacy in the prevention of CINV. Few adverse events were reported with NEPA; most that were observed were of mild-to-moderate severity, and there was no cardiac toxicity.

An oft-cited issue with NK1 receptor antagonists is that these drugs are inhibitors of the cytochrome P450 3A4 (CYP3A4) enzyme, which plays an important role in drug metabolism. Since many anticancer agents are metabolized through the CYP3A4 pathway, there is a significant potential for drug interactions, although to date, none of any clinical significance has been reported. Rolapitant (Varubi) is the most recently approved orally available NK1 receptor antagonist and was designed to address this issue to reduce the risk of drug interactions.

The FDA approved rolapitant in September 2015 based on data from three randomized, controlled, double-blind clinical trials. Two of these trials compared rolapitant with placebo in combination with intravenous granisetron and oral dexamethasone in patients receiving HEC. A third trial made the same comparison, using oral granisetron instead of an injection, in patients being treated with MEC or anthracycline-cyclophosphamide.

In all three trials, the complete response rate was significantly higher in the rolapitant arm during the delayed period after chemotherapy. The safety profile of rolapitant was similar to that of granisetron and dexamethasone alone.

A number of other pharmacologic agents have been tested for the prevention of CINV, including antagonists of other receptors thought to be involved in nausea and vomiting, as well as drugs approved for use in other indications for which the mechanism of action in CINV is unclear. In general, these drugs have lower therapeutic efficacy and greater potential for toxicity or their use is restricted to patients who are intolerant to standard antiemetics.

An exception is olanzapine, an antipsychotic that is thought to inhibit multiple receptors implicated in the pathophysiology of CINV. It has shown significant promise in phase III trials and, although it is not approved by the FDA for CINV prophylaxis, it is often used off-label by many oncologists. On May 16, 2016, the FDA issued a warning that olanzapine can cause a rare, but serious skin reaction.

Clinical trials suggest that olanzapine is as effective as NK1 and serotonin receptor antagonists at controlling vomiting, and may be more effective at preventing nausea. Additionally, it has been shown to be effective in the treatment of breakthrough CINV compared with the current standard of metoclopramide.

Preliminary results from a phase III trial of olanzapine in chemotherapy-naïve patients receiving HEC were presented at the 2015 Palliative Care in Oncology Symposium. The combination of olanzapine, aprepitant, and dexamethasone was compared with placebo, aprepitant, and dexamethasone. Significantly more patients reported no nausea with the olanzapine-containing regimen for both the acute and delayed period following chemotherapy.

Feature Story

The new generation of drugs that has emerged as part of antiemetic cocktails has demonstrated greater success in preventing and controlling chemotherapy-induced nausea and vomiting (CINV), but the symptoms&mdash;particularly nausea&mdash;still present significant obstacles in anticancer therapy, and the ultimate goal of prevention in all patients has yet to be attained.

Emerging Antiemetics Offer More Complete Control of Debilitating CINV

In planning this month’s cover story, I have to admit that I wasn’t in the least bit surprised to find that oncology nurses have been seizing on the opportunities technology can offer to improve the care of patients with cancer.

After all, nurses by nature are problem solvers, and they know where the gaps in care frequently occur. They also are often the first practitioner who patients, survivors, and caregivers come to with their questions and concerns. As Sarah Handzel, BSN, RN, writes: “Nurses are skilled at innovating. We have to be.”

In this month’s cover story, we spotlight examples of these innovations, some of which have been nurtured through the entrepreneurial MakerNurse movement, a community of inventive nurses creating solutions to improve patient care through tools, platforms, and training. We also report on a couple of tech-related interventions reported at the recent 2016 Annual Meeting of the American Society of Clinical Oncology (ASCO), that are aimed at systematically identifying patient side effects and signs of possible relapse early, when interventions can make the most difference.

Not to be outdone, nurses at the recent ONS Annual Congress also presented evidence-based projects that use technology to improve the patient experience, such as Google Translate to customize breast cancer treatment plans for non-native English speakers and setting up a user-friendly portal where oncology nurses can retrieve tumor-specific information and resources for their patients and their caregivers.

Improving the patient experience is at the heart of the Integrative Health and Wellness services radiation oncology patients are receiving at the NewYork-Presbyterian/Weill Cornell Lower Manhattan Cancer Center, where the focus, says Manna Lu-Wong, RN, is to provide compassionate, connected care to patients undergoing radiotherapy and thus help them to manage the side effects and stress that often accompany these treatments.

Likewise, chemotherapy-induced nausea and vomiting (CINV) is one of the most common and debilitating side effects of anticancer treatment, and in this issue, we provide an update on several new drugs that are improving the standard of care, particularly in the management of delayed CINV and in patients undergoing highly emetogenic chemotherapy.

Finally, we hear from “The Social Nurse” this month, who showcases our new #CureConnect Twitter chat, a collaboration of Oncology Nursing News and CURE magazine to provide a forum where oncology nurses, patients, caregivers, and advocates can learn from one another and share their combined knowledge.

We hope you will join this conversation, and also share any tech solutions (or non-tech!) you have found helpful in your own practice. Contact our managing editor, Lauren Green (

) to help us spread the word, and as always, thank you for reading.

From the Chairman

The Power of a Good Idea

Among the hundreds of studies presented at the recent 41st Annual ONS Congress were projects deploying tech solutions to address practice challenges in oncology care. Following is a sampling of some of these nurse-inspired ideas.

Breast Cancer Treatment Plans for Non-Native English Speakers

Patricia Kormanik, RN, MS, AOCNP, B-C, of UCSD Moores Cancer Center in San Diego presented findings of a pilot project using Google Translate to put the ASCO Breast Cancer Treatment Summa&shy;ry into the native language of these traditionally underserved populations. The cancer center serves an area where many non-English residents report native languages other than Spanish. Colleagues bilingual in Tagalog, Vietnamese, and Farsi checked the translated plans for accuracy and found them to be generally easy to use, readable, and comprehen&shy;sible. Any errors in grammar and syntax were easily corrected by the reviewers. (

One-Step Electronic Access to Patient Education Resources

Oncology nurses at University Hospitals Seidman Cancer Center (UHSCC) in Cleveland found that accessing resources for patients online was ineffi&shy;cient, time-consuming, and frustrating and often left patients with suboptimal information. Multidisci&shy;plinary teams were created to streamline the process and identify appropriate, tumor-specific patient education materials, along with developing a system for electronic chemotherapy drug regimen infor&shy;mation packets. Disease-specific shortlinks direct nurses to e-folders on the UHSCC intranet. Content is reviewed using health literacy best practices, key points are circled or otherwise highlighted for patients, and teach-back methods are used to confirm understanding. Materials in the folders also link back to the original documents to ensure patients receive the most current information. (

Personalizing Care Through a Telegenetics Program

A team of nurses at the New Mexico VA Health Care System (NMVAHCS) in Albuquerque wanted to im-prove prevention and personalized care at the hos&shy;pital by focusing on hereditary cancer risk, but their system lacked the professionally trained genetic counselors needed to support primary care physi&shy;cians who may lack specialized knowledge of genetic testing and how to interpret the results. To address this gap, NMVAHCS is working with the Veterans Affairs Genomic Medicine Service, based in Salt Lake City, Utah, to set up a telehealth service whereby con&shy;sultations are built into the patients’ computerized patient records, and staff members are trained on coordinating virtual appointments. The program was piloted initially with breast cancer risk evaluation (

). In the first week, 5 veterans were identi&shy;fied to receive the breast risk consults, empowering them with information to evaluate their risk-reducing options. The researchers concluded that collaborating with a proven VA genetics program saved money and “provided veterans with personalized, proactive therapeutic options.” (

Are you using a tech tool in your practice that you find especially useful? Send an email to 

). We’d love to hear more about it, showcase it on our website, and share the resource with your peers in oncology nursing.

_______________________________________________________________________

2016 Oncology Nursing Society Annual Congress: Podium, e-poster, and poster session abstracts. 

Research Wrap: Nurses Share Their Tech Ideas at ONS

Can I land my helicopter on top of the hospital? Can the doctor see my daughter before the clinic is open so she doesn’t miss too much work? Can you schedule my dog with a specialist at the veterinary school clinic? As navigators for the “special needs” population (aka VIP, or very important patients) at a top ten NCI-designated cancer center, these are actual questions from our patients, who most often are major benefactors to our institution. Though these may be atypical questions for healthcare navigators overall, we share common ground with all navigators: we recognize the specialized needs of our patients, and we engage in a trusting, helping relationship to facilitate optimal care.

Maybe you’re thinking that VIPs don’t visit your facility, but depending on how a VIP is defined, every healthcare facility can have VIP patients. Of course, famous people or public figures, such as professional athletes, rock stars and Hollywood actors are inherently considered VIPs, but 

 potentially could be designated as a VIP at a particular healthcare facility. Designated VIPs typically include benefactors, administrators, or donor prospects, but may also include the brother-in-law of the CEO or the cousin of a person connected with the facility, such as the dean or a top administrator.

When a person refers a patient to us and has labeled them a VIP, there may be an implicit or explicit message that this patient should receive “special care,” which is problematic in several ways. First, our providers, facilities, and health systems do wish to provide the same great care to everyone, regardless of status. Second, asking a healthcare professional to provide special care to a particular patient could imply that they are not providing great care to everyone, and the request could be received as an insult to their professionalism.

Of course as navigators, we’re not asking providers for different or better care, but sometimes notifying the staff of a person’s connection to our cancer center can be beneficial. For example, a physician may find it helpful to know that his patient is a local university president or a major benefactor who helped to fund the building we are working in.

As navigators, we use the term VIP judiciously when scheduling, as the term itself can be offensive to staff, especially because a goal of our facility is to reduce healthcare disparities. Many times providers and support staff have said to us that “everyone is a VIP” or, “I give the same care to everyone.” We would argue that some patients do need special considerations in deference to their position, status, or fame. For example, in this era of social media, a photo of a celebrity seated in the waiting area of a cancer center can be on the internet in a minute. Extending a small courtesy of arranging for a private waiting area can protect their privacy and identity, as well as their career.

Staff reaction to a VIP in the healthcare milieu can range from awe and admiration to resentment, which can affect the quality of care. If standard procedures are changed to accommodate the demands or expectations of a VIP, this can lead to predictable scenarios which have been organized into named syndromes in the medical literature. Psychiatrist Walter Weintraub wrote about 

 back in 1964; it’s initiated when standard care procedures are not adhered to, such as moving the location of care or switching providers. When rules are broken, it can contribute to care that is not better care, but actually worse than standard care.

Like all navigators working with specific populations, we’ve had to acquire a knowledge base of internal and external resources to help accommodate our VIP patients on a moment’s notice. Through in-person visits and frequent phone calls, we have developed relationships with colleagues in many departments at our facility. Transport will meet a patient at the front door at a specific time and Operations will help to ensure that the lab is ready for a patient. If we have a VIP who is an elected official or a public figure, we typically notify Security.

With our population we’ve become accustomed to receiving requests that are unrealistic. Patient expectations are high; they want their physicians’ cell phone numbers, e-mail addresses, and will often call them by their first name. Our patients are sometimes surprised that surgeons, for example, only see patients 1 day a week in clinic and therefore appointments are limited. Some may link their beneficence to the facility with expectations for same-day appointments for any malady or ‘front of the line’ expedited wait times in the Emergency Department.

As VIP patient navigators, we recognize that the financial resources at our patients’ disposal can move mountains. For example, one patient flew in from London for a single appointment and afterwards flew directly back. There are some VIP patients who we have never (or rarely) spoken to directly. Our relationship is often with their executive or personal assistants who have access to their schedules, habits, and preferences. For example one patient cannot be scheduled before noon on any date, due to his sleep schedule. Others are snowbirds and spend time here in the northeast and winter in Florida, so their medical appointments must be compressed into a brief window of time.

Patients call us miracle workers. Our success, at times, with setting up quick appointments with hard-to-get providers, can heighten their expectations for future encounters. We just try our best, every day. We are not successful every time, but we can appreciate these inspiring words of St. Francis of Assisi: “Start by doing what’s necessary; then do what’s possible; and suddenly you are doing the impossible.”

Sandra Blackburn has worked as a patient navigator, specifically with benefactors and other patients who are referred by Administration and Development, at the Abramson Cancer Center at Penn Medicine for nearly 15 years. Angela Moore joined the Abramson Cancer Center as a patient navigator in 2014 after a career at Health Partners, a Medical Assistance health plan, for 10 years as a case manager for the special needs and perinatal units.

Nurse Navigators

Can I land my helicopter on top of the hospital? Can the doctor see my daughter before the clinic is open so she doesn’t miss too much work?

Navigating "VIP" Patients With Cancer

Patients who are anxious and fearful as they embark on a course of radiotherapy to treat their cancer may find relief from those symptoms through relaxation techniques. A recent pilot project has found that a multimodal, multisensory wellness intervention can indeed make a difference.

The impetus behind this integrative health and wellness program at NewYork-Presbyterian/Weill Cornell Lower Manhattan Cancer Center (LMCC) was to provide “compassionate, connected care” to patients undergoing radiation and thus help them to manage the side effects and stress often associated with radiation treatments. The inspiration came from Leonard A. Farber, MD, clinical director of radiation oncology at LMCC.

To carry this mission forward, Manna Lu-Wong, RN, a dual-licensed nurse and acupuncturist, who is also certified in other complementary modalities including Reiki, Urban Zen Integrative Therapy, and Yoga4Cancer, was hired to provide integrative health and wellness services at LMCC in January, 2015. Shortly thereafter, Wong wanted to find out if the idea was working, and suggested, “Let’s do a pilot study to see if [these services] are having a significant impact on patients.”

The small study was carried out over 4 months and involved quantitative pre- and post-intervention assessments of 24 patients aged 40-79 years who were undergoing radiation therapy at the cancer center. The four-part relaxation intervention consisted of a 30-minute combined Reiki (healing touch), sound therapy, music therapy, and aromatherapy.

Each patient’s vital signs (blood pressure, heart rate, and respiration) were measured before and immediately following the intervention, as were their pain and anxiety levels using standard statistical assessments. Significant, immediate effects were observed in reduced heart rates and anxiety, said Wong, not only providing evidence of the benefits of the intervention for radiation oncology patients, but also establishing a rationale for further studies using a larger sample size and carried out over a longer period of time.

The serene Reiki room atmosphere at LMCC is designed to address multiple senses through its dim lighting, music, aromatherapy, and Reiki. Wong credits this combined approach for its success.

“I created a unique protocol that incorporates acupressure/self-massage, Reiki, music, sound healing (Tibetan singing bowls), breath awareness meditation, and yoga in one session.”

Wong said that she also assesses specific patient symptoms, and provides tailored treatments; for example, if patients have dry mouth, anxiety, or pain, she will instruct them in self-massage on areas that address these symptoms. For aromatherapy, lavender is helpful to address anxiety, and citrus/peppermint help with symptoms of fatigue or nausea. Breath awareness is also part of the protocol, and Wong typically ends the session with sound therapy playing the Tibetan singing bowls for about 5 to 10 minutes, all with the goal of relaxing the patient and reducing stress.

“Many studies show decreasing anxiety and stress reduce production of adrenaline and cortisol, thus improving the immune system,” Wong noted. “Providing these modalities readily to patients facilitates healing,” she continued, adding that patients often develop their own interest in the techniques and seek out Reiki, meditation, and aromatherapy after completion of their radiation course.

The relaxation modalities are fully integrated into LMCC’s radiation oncology unit. At the first radiation oncology consult, the free services are explained and offered to each patient. In addition, patients who show specific signs of anxiety prior to a radiation therapy session—for example, as a result of claustrophobia&mdash;can be referred by their nurses or other clinicians to the center for a brief Reiki or similar relaxation treatments.

For this population, Wong added, “fear and anxiety are among the more prevalent symptoms,” along with the cumulative effect of dealing with the cancer itself, and, for many, balancing the need to continue to work during treatment.

Patient feedback thus far has been extremely positive. “The patients love it, and they want to learn more about it,” said Wong. By offering the services and educating patients about their benefits, she added, “We are really promoting wellness.”

When patients are discharged from their radiation regimens, they often look for other practitioners so that they can continue the therapy, or, they find that they have learned enough about the process to integrate it into their daily lives.

While the program began specifically for the radiation oncology patient, Wong is now working with the Patient Family Advisory Council in promoting health and wellness at sponsored events. Alka Gupta, MD, and Chiti Parikh, MD, co-directors of Integrative Health at NYP Cornell, are implementing these health and wellness services in the health system.

“A lot has happened since our pilot study. It has set the stage for something bigger.”

Patients who are anxious and fearful as they embark on a course of radiotherapy to treat their cancer may find relief from those symptoms through relaxation techniques.

Relaxation Techniques Ease Patients' Fear, Anxiety About Radiation Treatments

My dad remembers the days when he saw his doctor’s face during a visit. Now, he says, he sees his doctor’s back as his doctor taps on the keyboard of his electronic health record (EHR). He also notes that even when computer screens allow more of a face-to-face interaction, healthcare providers nonetheless “keep their noses on the screen and not me.” What’s happened to high-tech, high-touch healthcare? Have we lost the high-touch component?

There are experts who believe that we may have. They note the realities of high-tech care, which require us to focus our attention on machines and leave little time for us to focus on the patient. In fact, many clinicians will tell you that they spend more time entering data into a patient’s EHR than actual time with the patient. It’s no wonder that patients describe these visits as distanced and dehumanizing. There are some who argue, however, that EHRs don’t impede these interactions but rather enhance them.

Perhaps the answer lies in how clinicians use technology and how patients perceive how it’s used. When clinicians allow technology to dominate—or overtake&mdash;the interaction with a patient, the high-touch component of healthcare diminishes or is altogether absent. I’ve had patients tell me that physicians have “examined them” without ever touching them. Equipment was used to measure their vital signs; patients entered their review of systems on tablets, kiosks, or computers; and laboratory and imaging study results were displayed on a screen.

Patients sometimes experience similar lack of human interaction in the infusion area. When nurses focus on the bar code on the armband instead of the person wearing the armband, it’s not surprising that patients find this interaction impersonal and distancing. When nurses “nurse the infusion pump” instead of the patient, patients may feel as if they don’t exist.

So how do we keep the high-touch in high-tech healthcare? One strategy is to use technology strategically and engage the patient in its use. Patients should be able to view screens containing their health information during their visits, and contribute to their health records via patient portals before, during, and after their visits. Having patients actively involved in the content of their records by contributing to them has been shown to increase patient acceptance of EHRs. EHR screens need to be positioned so that clinicians can maintain eye contact with the patient throughout the visit. When clinicians have their backs to the patient, they miss the patient’s nonverbal responses to the information being conveyed.

Some healthcare providers (mostly older in age) are employing “scribes” who type and enter information during a patient’s visit. In fact, “medical scribe” is now a recognized job title, and there are several online and in-person training programs available. Medical scribes have been described as a “revolutionary concept in modern medicine,” and are touted to relieve the “clerical responsibilities that slow physicians down and take them away from patient care.” Medical scribes are essentially personal assistants to physicians, performing real-time documentation in the EHR, gathering information for patients’ visits, and partnering with the physician to deliver more efficient patient care.

Another approach to enhancing the high-touch component of healthcare is to engage in purposive or intentional conversations with patients. For example, at one oncology facility, when nurses pulled up a chair to the patient’s chair or bedside, sat down, and talked to the patient, patient satisfaction scores increased. Interestingly, patients were asked how long the nurses sat with them and their responses averaged 10-12 minutes, when in actuality, the nurses were clocked sitting with the patient for no more than 5-7 minutes. Not surprisingly, nurses’ job satisfaction increased, with many citing that the focused nurse—patient interaction time rekindled the true essence of nursing.

The bottom line is that technology must be tempered by humanism. High-tech, high-touch care is possible, but requires clinicians’ dedication to its use.

Lisa Schulmeister, MN, RN, ACNS-BC, FAAN is an oncology nursing consultant and editor-in-chief of

Nurse's Notes

My dad remembers the days when he saw his doctor’s face during a visit. Now, he says, he sees his doctor’s back as his doctor taps on the keyboard of his electronic health record (EHR).

June 2016