	At age 40, Lisa Vance viewed her first mammogram more as a right of passage than a cause for concern. Even when she was told a biopsy would be needed, the mother of two was reassured by her physician’s assertion that he would be “very surprised if it turned out to be anything at all.”

	Despite this optimism, when Lisa had a biopsy following a suspicious finding on her mammogram, it revealed she had ductal carcinoma in situ. She was initially treated with lumpectomy, but subsequently had a right total mastectomy with immediate reconstruction.

	Lisa’s cancer was initially designated as stage I, but lymph node metastasis detected during her mastectomy necessitated four rounds of chemotherapy with dexamethasone, docetaxel (Taxotere), and cyclophosphamide (Cytoxan).

	During one of her chemotherapy treatments, Lisa had what she described as a “reaction,” feeling overheated and faint. The infusion was stopped, but Lisa was able to continue her treatment the same day, with the drugs infused at a slower pace. She also recalls feeling exhausted, especially after the later infusions; experiencing nausea and weight loss; and being extremely emotional.

	Lisa’s estrogen-sensitive malignancy also required treatment with tamoxifen (Nolvadex) and goserelin (Zoladex), initiated approximately one month after completion of her chemotherapy. In addition to feeling achy and experiencing bone pain, Lisa also experienced medically induced menopause as the result of her tamoxifen treatment.

	Lisa’s treatment was successful and she was declared “cancer-free” following a mammogram in July 2010. Subsequent mammograms, obtained twice annually, have continued to show no signs of cancer. Lisa’s goserelin was discontinued after two years; she will remain on tamoxifen indefinitely while being followed with semi-annual blood work.

	In March 2012, Lisa underwent endometrial biopsy after reporting to her OB-GYN with bleeding, despite having experienced menopause some two years prior. While her biopsy was negative for malignancies, Lisa will undergo robotic-assisted total hysterectomy with bilateral oophorectomy on June 26. According to her OB-GYN, the bleeding is most likely related to her tamoxifen treatment, and the procedure is being undertaken to prevent the development of endometrial and ovarian malignancies.

Whether surgically or medically induced, early menopause forces women to deal with a host of emotional, physical, and practical issues.

	As Lisa discovered, dealing with cancer is difficult enough without having to cope with the effects of treatment. And while most of those effects are temporary, menopause caused by medical or surgical interventions is a permanent reality.

	While natural menopause typically occurs at about age 51, and after a gradual transition, medically or surgically induced menopause can occur at any age and is much more abrupt. When surgically induced (bilateral oophorectomy), menopause occurs immediately and the abrupt decline in estrogen, progesterone, and androgen can cause symptoms (eg, hot flashes, vaginal dryness, difficulty sleeping, mood swings) that are significantly more severe than those experienced with natural menopause. When menopause is caused by medical interventions (various chemotherapy agents and pelvic radiation that damages both ovaries), there may be a brief transition while the ovaries gradually cease production of hormones.

	Indeed, women who experience induced menopause tend to require treatment for menopause-related symptoms more often—and sometimes for longer durations and at higher doses&mdash;than those who reach menopause spontaneously. Because cancer patients or surivors may be unable or unwilling to take hormonal medications, oncology clinicians need to be well-versed in the various nonhormonal treatments currently available for menopauserelated symptoms, or should consider referral to a practitioner with such expertise.

	Additionally, early or premature menopause (before age 40) puts women at increased risk for a number of conditions, such as osteoporosis, that were once kept at bay by normal production of estrogen. As with menopause-related symptoms, medical professionals need to be well-informed about a br oad range of pharmaceutical agents and lifestyle choices with the potential to help prevent and treat these conditions.

	Whether surgically or medically induced, early menopause forces women to deal with a host of emotional, physical, and practical issues—all in addition to the original diagnosis. While those who experience natural menopause often come to accept it as a new phase of life, the emotional consequences of early menopause can be quite different. Younger women like Lisa frequently express concerns about becoming “old before their time” or losing their femininity. For some of these women, the reality of being unable to bear children can be devastating.

	Ensuring that women fully understand the risk of early menopause both prepares women emotionally for the life transition and allows those concerned about reproduction to explore fertility preservation options. Furthermore, referral to a trusted source of information and support, such as The North American Menopause Society (

), a world leader in menopause information and education, can be invaluable in helping patients cope effectively, and as a resource for clinicians who want to learn more.

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

Articles

Patient Focus

Breast Cancer and Early-Onset Menopause

 Oncology nurses know the intricacies of cancer treatment. They know how to interact with patients in distress. And they know how to handle long-distance relationships. It is a skill nurses have developed in the past 10 years, as cancer treatment has largely moved into the outpatient arena. To help manage the side effects of chemotherapy, radiation, and targeted therapies, nurses often must contact patients at home, assess their conditions, and offer solutions—sight unseen.

	Checking in with patients can bring positive results, since oncology nurses are able to offer interventions for most symptoms of cancer treatment. But the process is not simple. It requires a great deal of insight from nurses, who must discern when patients are withholding information about their symptoms, when they are unlikely or unable to comply with their treatment plans, and when they need immediate medical attention. And determining how best to accomplish that from afar—without exceeding a practice’s resources&mdash; involves decisions about what to ask patients, when to contact them, and how.

	In general, clinics combine two strategies to track the well-being of cancer outpatients: educating them about what to expect, and then questioning them after treatment, either by phone or online, about how they are feeling and what kind of interventions they might need.

		Table. Common Symptoms of Cancer Treatments and Suggested Interventions

“Chemo brain,” or loss of memory and focus

					Confirm there is no infection, then Imodium

					Frequent sipping of water; artificial saliva; sugar-free hard candy

					Skin moisturizer; lowering of the dose of the therapy that caused the rash; antibiotic cream to prevent infection

					Pre-treatment education, so that patient can obtain preferred head covering; recommendation to cut hair short before it starts falling out

					Frequent, small meals; choosing foods that appeal; high-protein, high-calorie supplements; corticosteroids, if short-term

					Codeine; topical anesthetics such as lidocaine; oral narcotics such as Percocet; mouth rinses; sucking on popsicles during chemotherapy to reduce blood flow to mouth

					Antiemetic pills and patches, including Zofran; acupressure bracelets; steamed ginger

Numbness and tingling in fingers and toes

					If painful, nerve-based therapies such as antiepilepsy drugs; vitamin E; education to prevent tripping and other accidents

					If severe, natural or synthetic opioids; if less severe, or in conjunction with an opioid, anti-inflammatory medications

					Evaluation by psychiatrist or trained counselor; support groups; medication

Cover Story

Checking in with patients can bring positive
results, since oncology nurses are able to offer
interventions for most symptoms of cancer
treatment. Includes an in-depth look at telephone triage.

From a Distance: Managing Side Effects in Outpatients

	In part II of her article, Amy Sebastian-Deutsch continues to describe the potential for a collaborative relationship between Oncology Nurse Navigators (ONNs) and community health workers (CHWs). Sebastian-Deutsch discusses the development and implementation of a practicum through which ONNs would mentor CHWs, with the goal of facilitating improved cancer screening and care within the community. 

	The February 2011 meeting with Elizabeth Kelley, PhD, RN, CNS-CH, BC-HSP, (the driving force for the Houston Community College Community Health Worker Program) was behind me, and I had completed additional research to familiarize myself with CHWs and their role.

	It was now time to try to “pitch” the idea of an affiliation between my hospital system and the Houston Community College (HCC) for the purposes of providing practicum sites for the college’s CHW students. This would include practicum mentorship provided by our own oncology nurse navigators (ONNs). Knowing the size of our hospital system and the fact that I wanted to be ready to accept our first CHW students in June 2011 (only eight short months after first learning about CHWs), I knew it would not be a small challenge, and yet, I did not think it would be an insurmountable one.

	Let me first describe our hospital system. Memorial Hermann Hospital System (MHHS) is the largest not-for-profit healthcare system in Texas, and was recognized this year by Thomson Reuters as one of the top 15 healthcare systems in the United States. We serve the greater Houston community, which has a population of nearly six million. We comprise 21 imaging centers, 19 diagnostic laboratories, 10 surgery centers, 12 hospitals, eight breast-care centers, and seven cancer centers accredited by the American College of Surgeons Commission on Cancer (now recognized as an integrated network cancer program). Our academic campus, Memorial Hermann—Texas Medical Center, is part of the largest medical center in the world, the teaching hospital for the University of Texas Health Science Center (UTHealth) at Houston and the UTHealth Medical School. We are known locally for our Life Flight air ambulance program, which maintains six helicopters (including one strictly for pediatrics) and covers those within a 150-mile radius of Houston. We contribute in excess of $300 million annually for uncompensated care and community benefits.

	While I envisioned CHW students being mentored by any of our ONNs across any cancer diagnosis, the existing CHW student cohort was supported in part by the Houston Chapter of Susan G. Komen for the Cure, so the need to present my idea to the ONNs who navigated breast-cancer patients became my prime area of focus. Although I would have liked to have opened all seven of our cancer centers to the program, I knew I needed to first pilot this project at a few sites. Additionally, our breast-care centers are separate from the cancer centers, with separate administrative personnel. Therefore, both entities would have to agree on the pilot practicum program.

	It was important for me to approach the ONNs first, because without their approval, the program would not get off the ground. In April 2011, I approached the ONNs to discuss the CHW role and the HCC program, and to see who might be interested in being part of the pilot. Four ONNs expressed interest. I also spoke with both our attorneys and personnel from HCC to learn about the requirements of affiliation agreements and what changes might be necessary; I discovered that we would need to add CHWs to the current agreements. Unfortunately, given the time remaining, we could only get three practicum sites up and running.

	It then became necessary for me to confer with the directors of education to find out about our system’s requirements for students in clinical settings. While this would be primarily an observational experience, and CHW students would not be performing any patient chart documentation, it turned out that each student would still be required to complete specific facility orientations (including HIPAA requirements). Prior to that, they would need to obtain required immunizations, a tuberculosis test, a hepatitis B test, a drug screen, and a background check. They would also need to be CPR credentialed, and their school clinical instructors would need to sign off on everything.

	My next task was to develop a PowerPoint teleconference presentation to provide an overview of the proposed pilot practicum. Personnel from the respective institutes—including the ONNs, directors of education, cancer service-line administrators, and breast-care center administrators&mdash;were invited to participate. The proposed pilot was also presented during cancer committee meetings at the respective facilities. My objectives for these presentations were to describe the CHW role, the HCC CHW student program, how students would be mentored by the ONNs, and how the practicum would be rolled out at the chosen sites. I also hoped to gain the agreement of all parties to participate in the pilot.

	The following key points were presented:

		ONNs would not be obligated to take any students.

		Interested candidates would contact me via phone and briefly present themselves and their interests as well as their first, second, and third choices for practicum locations. They would be told there was no guarantee they would be offered a practicum.

		Selected potential candidates would then be referred to respective ONNs so they could be interviewed for “fit” with the facility and the populations being served. (Note: Some of the most positive outcomes have been achieved by CHWs who have worked within their own residential communities.)

		Summer practicum would begin in June 2011.

		Students would need to fulfill 224 hours over 12 weeks.

		If selected, students would be mentored by ONNs.

		Students would be rotated through multiple activities: clinic, exams, support groups, cancer treatments, and some of our community resource partner locations.

		Students would be required to complete a project deemed beneficial to themselves and their site’s ONN.

		Table. MHHS CHW Practicum Requirements (Based on DSHS Core Competencies for CHWs)

					Attend practicum "kick-off" meeting.

					Meeting with APN, ONN, and instructors; signatures of APN and ONN/facility educator

					Visit with city/state government official(s). Send birthday card (if applicable).

					Signature of legislative aide; copy of birthday card

					Identify patient in need of support (eg, newly diagnosed patient). Provide information/invite patient to support group.

					Survivor attends support group; confirmed by social worker or ONN signature

					Observe ONN/PT/MD interaction. Attend support group.

					Name of MD/signature of ONN; signature of ONN

					Follow patient across care continuum.

					Dates of attendance; signature of ONN

					Observe screening mammogram, diagnostic mammogram, breast biopsy, lumpectomy/mastectomy, XRT, and chemotherapy administration.

					Signatures of oncology nurses, mammography technicians, MDs, and ONN

Nurse Navigators

Amy Sebastian-Deutsch describes the potential for a collaborative relationship between Oncology Nurse Navigators and community health workers.

Oncology Nurse Navigators and Community Health Workers: Building Unique Relationships for Cancer Care, Part II of II

		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

	I recently overheard a conversation in the grocery checkout line that made me wonder how well we manage the side effects of cancer treatment. When the woman ahead of me in line told the cashier that she was sorry to hear that her father had died, the cashier responded by saying that “the cancer didn’t kill him, the treatment did.”

	Whether this was perception or reality doesn’t matter. What matters is that the cashier is not alone in believing the old adage that the treatment may be worse than the disease. It’s commonplace to hear newly diagnosed patients and their families talk about relatives, neighbors, and friends who underwent cancer treatment and experienced debilitating, and sometimes lethal, side effects. I imagine that I’m not alone in responding that every person undergoing cancer treatment is unique and that one person’s experiences (good or bad) cannot predict how another person will fare. However, at the same time, I wonder about patients who experience troublesome side effects and how well, or how inadequately, those symptoms have been assessed and managed.

	Patient assessment is a critical component of effective side-effect management. We need to know when a side effect began to occur, its intensity and duration, how it’s been managed, and whether it’s been managed effectively, partially, or ineffectively. Asking patients the question, “Any problems?” is not patient assessment. Patient assessment needs to include interview questions and a physical examination. Time and time again, I’ve observed nurses who took the time to review a list of possible side effects, and this review prompted patients to recall symptoms that they might not otherwise have mentioned (eg, “Now that I think about it, I do have a place in my mouth that has been sore.”). However, I’ve also seen nurses who record the patient’s responses to questions about side effects and stop there. In other words, a nurse will document a patient’s sore mouth, but not examine the mouth. When I asked a nurse about this once, she said that it didn’t matter if there was an observable sore in the patient’s mouth or not; it was sufficient that the patient had reported a sore mouth. It’s not sufficient; we need to take the next step and examine the patient. Managing the sore mouth of a patient who has lost weight and now has ill-fitting dentures is very different from managing diffuse stomatitis caused by chemotherapy or radiotherapy.

	Without a full understanding of what we’re treating, chances are that the patient will be inadequately and, possibly, inappropriately treated. Side effects that are mismanaged can cause patients to delay or drop out of treatment altogether. When patients say that they discontinued cancer treatment because they couldn’t handle the side effects, aren’t they really saying that their healthcare providers fell down on their jobs and failed to effectively manage those side effects?

	When patients say that they discontinued cancer treatment because they couldn’t handle the side effects, aren’t they really saying that their healthcare providers fell down on their jobs and failed to effectively manage those side effects?”

	Nurses sometimes think that side-effect management lies in the realm of medical or advanced nursing practice. However, drug information sheets and patient education materials typically instruct patients to report side effects to their doctors, nurses, and/or pharmacists. It’s our job—and duty&mdash; to appropriately and effectively manage those side effects. As patient-care providers, we need to be knowledgeable about current, evidence-based sideeffect management. At a minimum, we need to know what resources are available and how to access them (eg, National Comprehensive Cancer Network Guidelines, available at www.nccn.org; Oncology Nursing Society Clinical Practice Resources, available at 

; and Multinational Association of Supportive Care in Cancer Guidelines and Tools, available at 

	While some side effects require pharmacologic intervention, there are many that do not, and there are some that require both pharmacologic and nonpharmacologic approaches. Nurses have the opportunity to support patients and promote their comfort as they undergo cancer treatment; however, in order to achieve optimal outcomes for our patients, we need to have top-notch patient-assessment and side-effect management skills.

Nurse's Notes

It's commonplace to hear newly diagnosed patients and their families talk about relatives, neighbors, and friends who underwent cancer treatment and experienced debilitating, and sometimes lethal, side effects.

May 2012

Breast Cancer and Early-Onset Menopause

From a Distance: Managing Side Effects in Outpatients

Oncology Nurse Navigators and Community Health Workers: Building Unique Relationships for Cancer Care, Part II of II

The Treatment Should Not Be Worse Than the Disease