Because of the oncology nurse’s intimate role on the care team, patients often come to trust their nurse’s perspective, which positions the nurse as a go-to resource for all of the patient’s treatment related questions.

Whether they’re wondering about a drug’s adverse events, new treatments on the horizon, or alternative therapies, patients may expect their oncology nurse to help answer all their questions or at least point them toward the right resources. That is why it is vital nurses educate themselves on the latest insights in the rapidly changing field of oncology.

We strive to help oncology nurses with this in every issue of 

®, which is why our cover story breaks down relevant information in the use of 

. We interviewed experts in this field about the realties around the controversial topic, and when it is right to recommend marijuana use to patients, and how to break the stigma associated with marijuana.

Nurses are also tasked with understanding more about oncology outside their own specialty because of an unfortunate reality: The 

 creates a ripple effect across the field of oncology, cutting down nurses’ time at the bedside with their patients, sometimes compromising compassionate care. In this issue’s feature story, we focus on this adverse effect of the nursing shortage and how clinics can help address it.

It’s no secret that nurses are overburdened, so in these pages, one nurse addresses the issue of clinics forcing older nurses out of the clinic before they’re ready to retire and how clinics can instead step up to treat their employees fairly.

In their role as a resource, nurses also serve as advocates on their patients’ behalf, and can speak to issues their patients face with an insight other oncology professionals do not have. In this issue’s 

 you will read a nurse’s perspective on how African American women with breast cancer do not receive the same awareness and benefits that white women with breast cancer do.

 focuses on late-breaking studies and data from coverage at the European Society of Medical Oncology Congress 2019. Be sure to take the online quiz and earn 1 free hour of continuing education credit.

I hope you find this issue both enjoyable and informative, and as always, thanks for reading!

Articles

From the Chairman

Oncology Nurses Must Keep Up-to-Date to Deliver the Best Care

It’s not unusual for Carey S. Clark, PhD, RN, AHN-BC, RYT associate professor of nursing, University of Maine in Augusta, to have a patient ask if medical cannabis, also known as medical marijuana, might alleviate the adverse events (AEs) of cancer treatment. Many patients have heard anecdotal stories about how cannabis has reduced nausea, anxiety, pain, insomnia, and loss of appetite and are curious as to whether the plant-derived substance might work for them. As of August 2019, 33 states plus Washington, DC, have legalized medical marijuana, and 11 states and the District of Columbia have made it legal to buy and consume recreational marijuana.

“Nurses need to know the policies in their state concerning what patients can and cannot legally do around the use of medical cannabis,” says Clark, editor of the forthcoming 

Wolters- Kluwer Cannabis: A Handbook for Nurses.

In addition to her role as president of the American Cannabis Nurses Association, Clark has traveled across the country to help oncology nurses understand how they can best use cannabis as a palliative treatment, discuss cannabis ingestion and delivery methods, and note the proper dosage of cannabis for patients with cancer.

“With cannabis continuing to become legalized in more states across the country, there’s the need for oncology nurses to become familiar with the endocannabinoid system [ECS], the receptor system in the body that supports homeostasis and controls the central and peripheral nervous systems as well as energy uptake and immune responses,” Clark says.

“Patients have questions about medical cannabis use, and it’s important for nurses to have a working knowledge of the medical, legal, and pharmacological issues surrounding cannabis use.”

Although many oncology nurses and physicians are hungry for information on medical cannabis, the topic is traditionally never covered in nursing or medical school. The results of a University of Colorado Cancer Center study presented at the American Society of Clinical Oncology 2019 Annual Meeting show that while 73% of surveyed oncology providers believe medical marijuana provides benefits for patients with cancer, only 46% are comfortable recommending it. Major concerns included uncertain dosing, limited knowledge of available products and where to get them, and possible interactions with other medications.

Regardless of whether a state has approved cannabis for medical use, Clark says research shows that patients are turning to medical cannabis for help with chronic pain, depression, posttraumatic stress disorder, anxiety, spasticity among patients with multiple sclerosis, alleviating AEs of chemotherapy, and more.

Despite medical cannabis becoming more mainstream, Clark says a stigma still exists in many states and medical settings around its use. Some view medical cannabis as being in the same class of drugs as crack cocaine, while others remember “Reefer Madness,” the propaganda film that portrayed marijuana as a forbidden drug that might lead to psychosis and violence.

“There’s a lot of misinformation and fear that surround cannabis usage, and this makes it uncomfortable for many patients to discuss the topic with their provider,” Clark says.

A 2017 survey found that when patients aren’t able to obtain information about medical cannabis from their provider, they often turn to less-credible sources. The survey taken at a comprehensive cancer center in a state with legalized and recreational marijuana use found that although all patients preferred getting cannabis information from their provider, only 15% received that information. The majority obtained information from friends, newspaper/magazine articles, websites/blogs, or other patients.

“Nurses need to help end the stigma surrounding medical cannabis by supporting patients and being nonjudgmental, compassionate, and patient centered,” Clark says.

She cites how in July 2018 the National Council of State Boards of Nursing (NCSBN) published the NCSBN National Nursing Guidelines for Medical Marijuana, which outline principles of essential nursing knowledge as they relate to medical cannabis. They include a working knowledge of the current state of legislation of medical and recreational cannabis use, an understanding of the ECS, knowledge of safety issues related to cannabis use, and approaching patients without judgment regarding their treatment choices.

With the field of medical cannabis rapidly evolving, Judith Paice, PhD, RN, director of the Cancer Pain Program in the Division of Hematology-Oncology at Northwestern University Feinberg School of Medicine in Chicago, Illinois, encourages nurses to learn as much as they can. This knowledge, she says, will empower them to help patients make informed treatment decisions and determine if there are any drug interactions from other medications. It will also prepare nurses for other cannabinoid-based medicines that are currently being researched.

“In 2018, the Food and Drug Administration [FDA] approved Epidiolex [cannabidiol] for 2 types of epileptic seizures,” Paice says. “This might pave the way for patients to have access to more FDA-approved cannabis-derived drugs in the future.”

While interest in cannabis as a potential medication has increased, Paice says data are still lacking. “Cannabis research is rarely funded, but we’re starting to see more as researchers begin to look at whether medical cannabis can replace opioids or reduce opioid dependence or overdose,” she says.

In August 2019, Colorado became the third state, after New York and Illinois, to allow doctors to recommend medical marijuana for any condition for which they would prescribe an opioid. In addition, in Pennsylvania and New Jersey, patients with diagnosed opioid use disorder may be advised to use medical marijuana instead of opioids. The results of several studies show that cannabis use can lower opioid use in certain cases, but more research needs to be done in this area.

“Patients should be able to feel comfortable talking to their oncology doctors and nurses about cannabis as a potential treatment,” Paice says. “Even if we don’t have all of the answers, it’s important to keep an open mind and an open dialogue.”

Paice says it’s also important for nurses to know the different routes of administration for cannabis: oral, topical, and inhalation. Cannabis plant material can be smoked, vaped, ingested raw, or incorporated into edibles or beverages. Extracted cannabis oils can also be used topically and applied under the tongue. In addition, nurses need to learn the difference between tetrahydrocannabinol (THC), and the less-intoxicating cannabidiol (CBD).

Although THC and CBD are derived from the cannabis plant, THC is a psychoactive component that provides a “high” while CBD is a nonpsychoactive component that reduces inflammation. For this reason, Clark recommends that nurses advise patients using THC to “start low and go slow” with gradual increases until they reach a dosage that is controlling their symptoms.

“Having knowledge of medical cannabis can help nurses with patient education and coaching and help them to clarify their goals for medical use,” Clark says. “If a patient used marijuana recreationally in the past and had a negative experience, they may be cautious about trying cannabis again, but nurses can explain how to use it safely as a palliative tool without getting the feeling of being high.”

DISA Global Solutions. Map of marijuana legality by state. DISA website. 

disa.com/map-of-marijuana-legality-by-state

Glode AE, Wright GC, Leong S. Evolution of Colorado oncology providers on the use of medical marijuana. 

 2019;37(suppl 15):10511. ascopubs.org/doi/abs/10.1200/JCO.2019.37.15_suppl.10511.

Perfam SA, Woodfield MC, Lee CM, et al. Cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreation use. 

Russell K, Cahill M, Gowen K, et al. The NCSBN National Nursing Guidelines for Medical Marijuana. 

ncsbn.org/The_NCSBN_National_Nursing_Guidelines_for_Medical_Marijuana_JNR_July_2018.pdf

Bachhuber M, Arnsten JH, Wurm G. Use of cannabis to relieve pain and promote sleep by customers at an adult use dispensary [published online July 2, 2019]. 

Cover Story

Medical cannabis use is legal in more than half of the United States. Nurses who are well educated on the topic can improve patient care.

Medical Marijuana: Nurses's Knowledge Can Improve Patient Care

A nationwide nursing shortage is not only reducing the amount of time oncology nurses have to spend with their patients, but also increasing the risk for burnout and compassion fatigue.

 With the need for cancer care projected to outpace the supply of practitioners by 2025, nurses should use their time efficiently and take measures to avoid burnout.

Nurses at Kaiser Permanente in San Francisco, California took on this problem when they tackled staff inefficiencies in the infusion center by reconfiguring assignments and shift start times. They assigned each nurse to 3 chairs, located together, thereby creating teams in adjacent areas to simplify medication checks and break coverage. In addition, they staggered shift start times by 30 minutes, providing nurses with needed prep time.

Survey results collected after the pilot run (45 shifts) and presented at the 44th Annual Oncology Nursing Society (ONS) Congress showed that nursing satisfaction with patient location, ability to see patients, handoffs to colleagues, and prep time skyrocketed.

 Overall patient satisfaction also improved. The results were impressive enough that plans were made to implement the new workflow throughout the rest of the clinic.

Reducing patient wait times was a project goal set by nurses at the Adult Infusion and Medical Clinic at UF Health, in Gainesville, Florida.

 They recognized that communication problems were delaying treatment start times due to unsigned, incomplete, or unclear orders. Electronic health record dashboard reports and secure messaging were used along with interdisciplinary education, intervention meetings, and communication cards, to reduce patient treatment delays by an average of 6.5 minutes. This quality improvement measure also increased communication within the team. By making a few meaningful changes, the nurses realized a significant difference in workflow and improved satisfaction for patients and staff alike. With less time available for patients, and growing demand for cancer care services, nurses may find themselves suffering from emotional exhaustion, compassion fatigue, or burnout. Victoria Reiser, BSN, RN, ONC, and Judy Zedreck, DNP, MPM, NEA-BC, work at the University of Pittsburgh where they developed personalized self-care toolkits for combating compassion fatigue among nurses at 2 oncology units in the teaching hospital.

The toolkits were rarely used, so they sought to uncover barriers to self-care through focus group discussions based on 4 main themes: leadership, work schedule, acuity and staffing, and personal barriers. They presented the results of their project at the ONS Congress in 2019.5 “Nurses are always putting their patients first,” Reiser shared in a recent interview with 

. “They know what compassion fatigue is, and they know what they are doing that puts them at risk, but they really want to be there. They want to take care of their patients.” Reiser says she believes that nurses need self-care to not take them away from the bedside. Rather, that care needs to be built into daily practice, beginning with orientation. “We need to teach nurses to nurture their young nurses and show them what those nurturing habits are.”

Zedrech, who is program coordinator for the university’s Doctor of Nursing Practice Health Systems Executive Leadership Program, agrees and urges administrators and leaders not to assume they know what nurses need. “Whether it’s another nurse, an aide, equipment, or other things, nurses want validation from leadership that the work they do is important, but they have to communicate on the same plane.” She sees burnout not so much as a by-product of the work or the intensity of the job, but of nurses not having the tools they need to do the work they love.

Still, there are ways to help nurses avoid fatigue and burnout. First, return to the basics. Make sure nurses are taking their breaks, especially for meals. Encourage coworkers to talk to each other about their stress and with leadership about solutions. Help staff integrate self-care habits into their work day instead of making it another task to complete. Schedule breaks and make time off the unit part of daily practice. Recruit informal leaders as role models of self-care. The solution does not have to be groundbreaking.

When it comes to fatigue, nurses don’t want to complain. They want to be there for their patients who are suffering and struggling. Reiser shared that “compassion satisfaction is stronger than compassion fatigue. Nurses love this job, and they stay because they derive a lot of satisfaction from caring for these patients.” Zedreck concurred, adding that “people stay when times are rough—when they trust leadership is doing the best they can do.”

1. Toh SG, Ang E, Devi MK. Systematic review on the relationship between the nursing shortage and job satisfaction, stress and burnout levels among nurses in oncology/haematology settings. 

. 2012;10(2):126-141. doi: 10.1111/j.1744-1609.2012.00271.x.

2. Chandak AN, Loberiza FR Jr, Deras M, Armitage JO, Vose JM, Stimpson JP. Estimating the state-level supply of cancer care providers: preparing to meet workforce needs in the wake of health care reform. 

. 2015;11(1):32-37. doi: 10.1200/JOP.2014.001565.

3. Beringer K, Jansen C, Tejada M, Wong A. Improved nursing infusion workflows, including chair assignment grouping, increase nurse and patient satisfaction. Presented at: ONS 44th Annual Conference; April 11-14, 2019; Anaheim, CA.

4. Pesata B, Farrar R, Harris L. Improving speed, efficiency, and communication of medical oncology patients receiving infusion treatments. Presented at ONS 44th Annual Conference; April 11-14, 2019; Anaheim, California.

5. Reiser V, Zedreck J. Barriers to self-care and combatting compassion fatigue among oncology nurses. Poster presented at: 2019 Creating Healthy Work Environments Conference; February 2019; New Orleans, LA. bit.ly/2PoedbB.

Feature Story

Improving Compassion Satisfaction Amid a Nursing Shortage

Quite simply, there is no good or harm-free exemplar of smoking. Tobacco use entails embarking on a slow course of ruining your life, which is why I am vigilant when it comes to the subject. My father and husband died from cancer caused by long-term tobacco exposure. It is also impossible for me to count how many patients I have cared for over the years who have voiced their regrets for trying that first cigarette.

A disclaimer is in order here. I have never smoked. In 8th grade, we were shown a movie about the dangers of tobacco, which included a graphic picture of blackened lungs that scared me. I went home and made a plea to my parents who both smoked, to stop. For most, however, it is not that simple. Nicotine addiction is extremely difficult to overcome.

Now we have a new tobacco-related epidemic on our hands: vaping. The old record from decades ago about the absence of harm from tobacco has been dusted off and replayed,

but the target for current marketing efforts is different. Children, mostly teenagers, are the focus. The deceit has been so significant that in September of this year, the FDA threatened sanctions against Juul Labs, a major producer of vaping products, for erroneous and misleading marketing to children and teenagers about the “less harmful” nature of e-cigarettes.

Electronic nicotine delivery systems (ENDS) are designed to aerosolize liquids for inhalation. These devices include e-cigarettes, vaporizers, hookah pens, and tank systems, predominantly used to inhale nicotine and cannabis-based compounds. E-cigarettes entered the US market around 2007, and since 2014, they have been the most commonly used tobacco products among youths nationally.

By 2018, there were 288 models of ENDS on the market and more than 15,500 flavors, referred to as juices.4 Vaping behaviors also escalated considerably in high school students between 2017 and 2018.5 An extensive review of monitoring results of over 43,000 students in 8th, 10th, and 12th grades between 2017 and 2018 revealed vaping-related incidences more than doubled in each of these 3 grades. In 2019 alone, the prevalence of vaping in the 30 days before student survey completion was more than 1 in 4 students in 12th grade, more than 1 in 5 in the 10th grade, and more than 1 in 11 in the 8th grade.

 The range of flavor options and the perceptions that vaping is relatively healthy and more socially acceptable than tobacco are considered to be the major drivers in this dramatic increase in use.

As vaping continues to become a widespread issue, many are concerned with its connection to pulmonary diseases. Researchers studied the clinical courses of 53 patients who

were identified in acute-onset pulmonary disease clusters in Wisconsin and Illinois.

Fifty patients were hospitalized, 32% of whom required intubation and mechanical ventilation; 1 death was reported. The median age of these patients was 19 years. All reported e-cigarette device used before the onset of symptoms, the majority of which (84%) inhaled tetrahydrocannabinol products.

Several recent reports detailing biopsy and radiological findings are of particular interest to researchers and public health officials. The acute lung injuries associated with vaping

were primarily identified as hypersensitivity pneumonitis, diffuse alveolar hemorrhage, and histopathologic variations of pneumonia.

 The causes remain speculative, but potential etiologies cited include the aerosolization of flavoring compounds, adulteration of devices with tetrahydrocannabinol-based oils or vitamin E, and use of black market vaping products.

The most recent report of a negative vaping corollary was the development of lung and bladder primary cancers in an animal model where short-term (12 weeks) e-cigarette smoke exposure in mice was associated with the presentation of these malignancies.

The United States needs to set a global example for the prevention of ENDS-related illnesses. To do this, 4 phenomena must be addressed:

1. The young age of ENDS users is of utmost concern. Continuous, unconstrained use of ENDS in this demographic represents the first generation

of teenagers in the modern world to be allowed to put their health and longevity at risk, unchecked, with alleged long- term negative corollaries.

2. The addictive nature of nicotine, especially in young individuals, cannot be ignored. Efforts to protect youth from using nicotine during adolescence is imperative. The developing brain is particularly susceptible to permanent changes from nicotine use.

 Results of epidemiological studies have also shown that smoking in this age group is a first step toward heroin and cocaine addiction.

 Chemical changes in dopamine-receiving neurons induced by nicotine are likely to disrupt the brain’s normal reward circuitry and prime the brain for enhanced sensitivity to potentially abusive substances.

3. Vaping may increase the incidence of dual users of nicotine products. There is growing evidence that rather than substitute conventional tobacco for e-cigarettes, there are more dual users—those who vape and smoke cigarettes.

4. ENDS may be linked to future cases of lung cancer.5 Due to the contemporary nature of this epidemic, the long-term consequences of this health risk are unknown. However, due to historical data associated with nicotine use, it is highly suspect that a link between e-cigarettes and cancer will unfold.

Oncology nurses must keep up with the evolving scientific basis of the perils of vaping.

As trusted educators, we need to maintain informational vigilance about this health hazard. This topic may evolve in discussions with patients as the use of cannabis products during cancer treatment is deliberated. It may also present as patients and families voice concern about their children’s or grandchildren’s use of ENDS. I don’t feel this phenomenon will go away soon, which is all the more reason to focus on our evidence-based astuteness as we advocate for patients and families and perhaps our own loved one.

Marcham CL, Springston JP (2019). Electronic cigarettes in the indoor environment. 

Warning letter to JUUL Labs; accessed 10/10/2019; 

https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/juul-labs-inc-590950-09092019

Surgeon General’s advisory on e-cigarette use among youth. Washington D.C.: Department of Health and Human Services, Office of the Surgeon General, 2018 (

https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018-pdf

Henry TS, Kligerman SJ, Raptis CA, Mann H, Sechrist JW, Kanne JP (2020). Imaging findings of vaping-associated lung injury. 

Author (2019). Vaping-related lung illnesses: Time to act. 

Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME (2019). Trends in adolescent vaping, 2017-2019. 

Layden JE, Ghinai I, Pray I et.al. (2018). Pulmonary illness related to e-cigarette use in Illinois and Wisconsin — Preliminary report. 

Butt YM, Smith ML, Tazelaar HD et.al. (2019). Pathology of vaping-associated lung injury. 

Hswen Y, Brownstein JS (2019). Real-time digital surveillance of vaping-induced pulmonary disease. 

Tang M, Wu X, Lee H et.al. (2019). Electronic-cigarette smoke induces lung adenocarcinoma and bladder urothelial hyperplasia in mice. 

Yuan M, Cross SJ, Loughlin SE, Leslie FM (2015). Nicotine and the adolescent brain. 

Kandel ER, Kandel DB (2014). A molecular basis for nicotine as a gateway drug. 

The Disordered Mind: What Unusual Brains Tell Us About Ourselves. 

Brandon KO, Simmons VN, Meltzer LR et.al. (2019). Vaping characteristics and expectancies are associated with smoking cessation propensity among dual users of combustible and electronic cigarettes. 

Giovenco DP, Delnevo CD (2018). Prevalence of population smoking cessation by electronic cigarette use status in a national sample of recent smokers. 

Nurse's Notes

Tobacco use among young people is an old problem that now challenges a new generation in a new form: vaping.

Vaping Presents an Old Danger to a New Generation

“Your final surgical pathology results confirm stage III ovarian cancer, and with your strong family history of maternal breast cancer and maternal aunt with ovarian cancer, I recommend we perform genetic testing.” As a gynecologic oncologist, this is an all too familiar conversation. Ovarian cancer is the fifth leading cause of cancer death in women, making it the deadliest of all gynecologic cancers with no screening tool. These facts are exactly why we advocate for preventive measures for ovarian cancer and the 4 other gynecologic cancers: cervical, uterine, vaginal, and vulvar.

Making sure your patient knows their family history is the first preventive step any woman can take to avoid a diagnosis of ovarian cancer. Twenty percent to 25% of all cases of ovarian cancer are due to genetic mutations, with BRCA mutations accounting for about 16% of those cases.

Following genetic testing and in cases of a confirmed mutation, we can provide patients with preventative surgeries that remove the fallopian tubes and ovaries, dramatically reducing this risk of cancer.

Once your patient understands their genetic profile, you can help prevent the recurrence of this deadly disease by using targeted therapies proved to prolong life without disease recurrence or progression. Next up on the list of gynecologic cancers are 3 of the 5 that fall into the category of human papillomavirus (HPV)-related cancers: cervical, vulvar, and vaginal cancers.

With the development of the HPV vaccine, now available to women up to the age of 45, we can prevent these cancers and have the potential to eradicate them. Seems like a no-brainer to have your patients understand this treatment and get vaccinated. Not only does the vaccine prevent these cancers, it prevents and can help treat dysplasia, a pre-cancer that transforms into cancer of these organs if left untreated.

Finally, uterine cancer, of which endometrial cancer is a subtype, is the most common of the gynecologic cancers. A major risk factor for endometrial cancer is higher than normal estrogen stimulating the uterus, which can come from our fat tissue. Women who are overweight or obese have a much higher risk of developing this cancer. Additionally, extra estrogen exposure can come from hormone replacement therapy, which some women may start in the peri- and postmenopausal phases of life.

I focus my prevention strategies for endometrial cancer on encouraging my patients to maintain a normal body mass index with regular healthy diet and exercise; to use with caution the lowest doses for the shortest amount of time, if exploring hormone replacement therapy; and to get genetic testing if there is a strong personal or family history suggestive of Lynch syndrome.

 mutation in ovarian cancer: testing, implications and treatment considerations. 

. 2017;9(8):519-531. doi: 10.1177/1758834017714993.

To learn more about gynecologic cancers, genetics, clinical trials, and survivorship, I encourage you to visit the Foundation for Women’s Cancer website (foundationforwomenscancer.org) and share what you learn with your family, friends, and colleagues. 

Partner Perspectives

Gynecologic cancers present some of the most dangerous cancer-related threats to women, here's how to help patients understand what to look out for and the realities of their treatment. 

November/December 2019

Oncology Nurses Must Keep Up-to-Date to Deliver the Best Care

Medical Marijuana: Nurses's Knowledge Can Improve Patient Care

Improving Compassion Satisfaction Amid a Nursing Shortage

Vaping Presents an Old Danger to a New Generation

Helping Your Patients Understand and Prevent Gynecologic Cancers