	Otolaryngology Clinical Nurse Specialist

	The Ohio State University Medical Center, Columbus

	There are already inherent difficulties when treating patients with glioblastoma, including the stress to patients and families that are often dealing with personality changes in the patient. In addition, there are often adherence issues when giving oral therapies to patients. The additional risk of seizure activity in these patients can only add to the already mounting stress for patients and families. Therefore, the addition of an AED is imperative for many patients.

	Given the variety of AEDs available, the findings of Weller, et al are encouraging. The fact that we can increase overall survival with valproic acid should be considered significant; however, this survival benefit does not come without its own cautions.

	As discussed in the article, patients treated with valproic acid have increased incidence and severity of thrombocytopenia and leukopenia. It would be imperative for nurses to educate the patient and family on precautions to take for thrombocytopenia and leukopenia, and to encourage them to call their healthcare provider with any indication of bleeding or infection. A thorough physical assessment would be warranted in order to uncover subtle changes that may detect thrombocytopenia or leukopenia before they become severe. In addition, a social history including living conditions and activities should be completed to reveal any risks that need to be addressed.

	Weller et al are also clear to point out that there are some shortcomings to their study that may warrant additional research, but that these encouraging results may help guide us in the choice of AEDs in patients receiving the current standard treatment. As always, the nurse is in a perfect position to discuss these findings with the physician and advocate for the patient when appropriate.

Valproic Acid May Prolong Survival in Glioblastoma

	Trastuzumab (Herceptin) and lapatinib (Tykerb) have proven to be very valuable in treating patients with HER2-positive invasive breast cancer. While efforts to improve HER2 testing continue, the most important aspect is to create a system of uniformity in testing and interpretation.

	The goal is to make sure everyone who could benefit from these medications is receiving them. Therefore, it is imperative that quality standards are instituted, as well as followed, in order to prevent false negatives that might prevent a patient from receiving this worthwhile treatment.

	Protocols do not appear to be enough to standardize this process. Additional coordination of the tissue is essential. As the number of testing sites increases and these medications are being successfully used in other disease processes, we are now talking about life or death in terms of whether the test is done correctly or not.

	There must be standardized proficiency testing for IHC, FISH, ER, and PgR markers. It is not a question as to which one might be best, but rather attending to the details of how the test should be performed and read, which will ultimately improve the performance of these tests. In the end, it is important to have a test that is as reliable as the treatment that is offered.

Efforts to Improve HER2 Testing Continue ASCO Panelist Sees Progress

	Issues with completion rates for vaccination with the human papillomavirus (HPV) infection can be related to scheduling; however, knowledge gaps in parents and teenagers regarding HPV vaccination can also strongly affect the likelihood of complete vaccination.

	Parents need to be made aware that efficacy of the vaccine is not accomplished until the vaccine series is completed. With constant controversy over vaccines being considered a health risk, perception is critical. Addressing questions and educating parents and teens on vaccination efficacy needs to be a high priority before starting the process. Healthcare professionals should describe not just what the vaccine is treating, but what follow-up dosing involves, and the time frame for each vaccine. Being forthcoming and having a “treatment plan” prior to patients leaving the office reduces the likelihood that the adolescent or the parent would potentially not remember a scheduled dose.

	One distinct advantage of the adolescent generation being more tech savvy is the ability to create a reminder system for the teenager and for the parent through e-mail or cell phone to keep all parties connected. The prior scheduling of the second and third doses is one way to keep on track. Providing a prerecorded message or an e-mail as a reminder at different intervals can help with adherence and reduce the vaccination completion gap.

HPV Vaccination Completion Rates Increase, but Gaps Remain

	Laura Metcalfe, MSN, RN, APN, C, AOCNS®

	John Theurer Cancer Center, Hackensack, New Jersey

	The adoption of a “prudent” diet has been well established as a strategy to reduce one’s risk of colorectal cancers. The American Cancer Society (ACS) recommends 5 or more servings of vegetables and fruits daily, whole grains instead of processed grains and sugars, and limited red meat consumption, especially high-fat and processed meats. Further, the ACS recommends maintaining a healthy weight, limiting alcoholic beverages, no smoking (as well as limited exposure to secondhand smoke), and adopting a physically active lifestyle as further risk-reduction strategies.

	This study looked only at black women, and one must always be careful about applying findings across heterogeneous groups; however, I personally believe that adopting a prudent diet would significantly decrease the number of colorectal cancer diagnoses for those people with no other risk factors (ie, inherited genetic abnormality, inflammatory bowel disease, personal history of colonic polyps). Further, a 2007 study published in the 

Journal of the American Medical Association

. 2007;298[7]:754-764) showed that colorectal patients with the highest intake of a Western-pattern diet, characterized by high intakes of red meat, sugar desserts, high fat, and refined grains, have a three-fold increase in cancer recurrences and mortality.

	Given that a prudent diet has other health benefits, including, but not limited to, reducing obesity, and subsequently, the risk of hypertension, diabetes, and heart disease, I see no downside to adopting the type of diet discussed in the study. I recommend it for anyone looking to decrease their colorectal cancer risk or just looking to improve their overall health.

Prudent Diet May Help Prevent Colorectal Adenomas in Black Women

	Assistant Director, Senior Medical Liaison

	Elderly patients (mid-70s and older) with NSCLC are more likely than their younger counterparts to receive a single chemotherapeutic agent, not the general standard of care—a platinum or taxane-based doublet regimen with or without an added biologic agent. However, as the first wave of baby boomers is set to become octogenarians, we can expect a uniquely different elderly patient: a healthier, more driven, independent, and educated healthcare consumer who actively participates in his or her care.

	Therefore, the traditional or “typical” approach to treating these patients must continue to be tested and evaluated. As discussed in the above article, this approach has been tested for its efficacy and safety in an important multicenter, phase III study (IFCT-0501) comparing carboplatin and paclitaxel doublet chemotherapy regimens (the standard of care) to monotherapy regimens in elderly patients (aged 70-89 years) with advanced or metastatic NSCLC. The study met its primary endpoint of overall survival (OS), with a median OS benefit of 4.1 months in the doublet arm.

	These findings offer important evidence that elderly patients with advanced or metastatic disease be considered for standard treatment despite increased toxic effects (most frequent: neutropenia and asthenia). Further, reconsideration of how the current standards of therapeutic care are applied to elderly NSCLC patients is necessary, as oncology care continues its transformation to become more personalized through genomic testing and targeted treatment approaches. With the rapid advancements in lung cancer and the entry of technologies and targeted agents, it is essential that we better understand the mechanism of action and its implications as side effects arise so that we may educate our patients and sharpen our patient assessment skills.

	It is within this historic collision of medical science and generational patient shifts that we find opportunities for the nursing profession and for nursing research, some of which should include:

		Nursing participation in conducting quality-of-life studies related to the elderly cancer population.

		Nursing development/contribution of clinical guidelines to help develop new standards of care that incorporate both the physical and psychosocial aspects of a patient’s history to help guide selection of treatment.

		Nursing development of patient advocacy materials to promote shared decision-making.

Adjusting Chemotherapy in Octogenarians With NSCLC

Articles

Feature Story

Nurses provide their unique perspectives on many of the recent clinical trials and developments in cancer research.

October 2011: Nurse Perspectives on Developments in Cancer Care

New findings demonstrate a recent increase in the annual completion rates of vaccination against human papillomavirus (HPV) infection, which is a necessary cause of cervical cancer. However, the data, from a large and nationally representative sample of female adolescents, also show that significant gaps persist in vaccination completion according to race/ethnicity and poverty.

	Linda M. Niccolai, PhD, with the Yale School of Public Health in New Haven, Connecticut, and associates used data obtained in the 2008 and 2009 National Immunization Survey on teenage girls (NIS-Teen) who received at least 1 dose of HPV vaccine.

	Two HPV vaccines are approved by the FDA to protect against HPV-16 and HPV-18, which are responsible for 70% of cervical cancer cases. The Advisory Committee on Immunization Practices (ACIP) recommends the routine use of either vaccine in a 3-dose series for girls aged 11 or 12 years. The second and third doses should be given at 2 and 6 months, respectively. A catch-up vaccination is also recommended up to age 26 for girls and women who did not previously receive all 3 doses.

	Several studies have documented suboptimal HPV vaccination completion rates ranging from 13% to 16%. White adolescents have been found to be more likely to complete the series than Hispanics and blacks, and teens with private insurance were more likely to complete the series than teens with public insurance.

	However, prior studies showing disparities in HPV vaccination completion have been plagued by limitations. For example, the earlier investigations did not directly examine completion rates using multivariate modeling to assess independent correlates of completion. They have also been limited by small "and possibly nonrepresentative samples."

	The primary outcome measure in the present study was completion of the 3-dose series defined as having received at least 3 doses of either vaccine as documented in healthcare provider reports.

	Overall, 55% of girls who had initiated HPV vaccination completed the 3-dose series, 21% received 1 dose, and 24% received 2 doses.

	The percentage that completed the series was significantly higher in 2009 than 2008 (60% vs 48%; 

	After adjusting for covariates, including access to care, adolescents who were black (adjusted odds ratio [AOR] = 0.48; 95% confidence interval [CI] = 0.40-0.57) or Hispanic (AOR = 0.75; 95% CI = 0.64- 0.88) were significantly less likely to complete the vaccination series than whites. Adolescents living below the federal poverty level were significantly less likely to complete vaccination than adolescents with household incomes > $75,000 (AOR = 0.76; 95% CI = 0.63-0.92).

	The interaction between race/ethnicity and year was not significant (

	Niccolai et al described the hike in HPV vaccination completion rates from 2008 to 2009 as "far from optimal" but "encouraging." Completion of the vaccination series may be problematic because the first dose may be administered at a routine yearly preventive appointment, but the second and third doses require follow-up visits. These subsequent appointments, in turn, call for "knowledge, motivation, positive attitudes toward vaccination, and additional financial resources such as the ability to pay for vaccine or, if the cost of vaccine is covered by health insurance or a government program, the ability to take time off work for parents, transportation visits, or office visit copayments."

	The authors caution that the precise extent to which the study cohort is representative of all adolescents living in the United States is not known despite a "strong survey design and use of weights." A major reason is that the study lacked potentially important information on doses of HPV vaccine given by providers other than those who responded to the provider survey. In addition, the study was not able to determine whether adolescents who had not completed the vaccination series had not done so because they had only begun the series within the prior 6 months.

	Also, the NIS-Teen survey did not include other factors that might be relevant, including the employment status of the parents and family structure.

		Niccolai LM, Mehta NR, Hadler JL. Racial/Ethnic and poverty disparities in human papillomavirus vaccination completion. 

New findings demonstrate a recent increase in the annual completion rates of vaccination against human papillomavirus (HPV) infection.

 The Cancer Legal Resource Center (CLRC) is a national, joint program of the Disability Rights Legal Center and Loyola Law School Los Angeles. The CLRC provides free information and resources on cancer-related legal issues to cancer survivors, caregivers, healthcare professionals, employers, and others coping with cancer.

	A cancer diagnosis may carry with it a variety of potential legal issues relating to insurance, access to care and government benefits, consumer rights, estate planning, and employment.

	The CLRC provides a comprehensive array of free services in English and Spanish to individuals coping with cancer-related legal issues. The CLRC hosts a toll-free, national Telephone Assistance Line (866-THE-CLRC) where callers can receive free and confi dential information about relevant laws and resources for their particular situation. Individuals may also access the Telephone Assistance Line by completing an online intake form on the CLRC’s website at 

	The CLRC website also features a variety of state and national resources in English and Spanish, including 

The HCP Manual: A Legal Resource Guide for Oncology Health Care Professionals

. This guide serves as a reference on key topics to assist healthcare providers in navigating their patients through these systems.

 The CLRC has provided over 235,000 people with information on cancer-related legal issues through our national Telephone Assistance Line and our activities in the cancer community. There is no other program in the country like the CLRC, which is why the American Cancer Society and many other national organizations refer their callers with legal questions to the CLRC.

	Joanna L. Morales, Esq., Director of the Cancer Legal Resource Center spoke with 

 at the recent National Coalition of Oncology Nurse Navigators 3rd Annual Conference. Morales discussed a variety of topics, including the need for oncology nurses to be proactive in asking their patients about cancerrelated legal issues. She suggested some potential questions nurses could ask their patients:	

Do you understand how your insurance coverage is going to cover your treatment and how it might not? 

Do you know what resources are available to help you navigate through your insurance coverage? 

Do you have any trouble with your employer? 

Are you concerned about going back to work? 

Are you concerned about working through treatment and how the side effects of treatment might be affecting your ability to work?

 Morales also described legislation that applies to legal issues concerning patients with cancer. “The most helpful laws for people with cancer are often laws that have to do with disability….[For example] we have laws in the employment arena like the Americans with Disabilities Act [ADA] and individual state fair employment laws, which are usually similar to the ADA. And then we have laws like the Family and Medical Leave Act that protect people’s ability to take time off from work [and] protect their insurance benefits if they get their benefits through their employer, and to be able to return to the same or a similar position [after treatment]. So it depends on the area of the law, but there are usually laws that either provide protections or provide access to benefits or programs.”

	To view our entire interview with Morales, go to 

	In addition, callers may be referred to a member of the CLRC Professional Panel, which includes attorneys and other professionals from across the country, to provide free consultations for CLRC callers who may need additional information about their specific situation.

	The CLRC also travels around the country to provide educational seminars, host Cancer Rights Conferences, and attend outreach events in the cancer community.

	The CLRC is proud to host the 2011 Cancer Rights Conference Series in Chicago (June 24, 2011), Washington, DC (September 23, 2011), and Ann Arbor, Michigan (October 21, 2011). The Cancer Rights Conferences are free 1-day conferences where participants receive comprehensive information about the most common cancerrelated legal issues, including employment and taking time off from work, insurance options and navigation, genetic discrimination, and estate planning. These conferences are attended by patients, survivors, caregivers, healthcare providers, advocates, and business and community leaders. Attending attorneys, nurses, and social workers may be eligible to receive up to 9 hours of free CEU’s.

	The Conferences have been very well received and have provided invaluable assistance to those who attended. As one attending healthcare professional from the 2010 Los Angeles Cancer Rights Conference remarked, “The information presented in this venue is immeasurably important to me in my role as an oncology-certifi ed RN, as a person, and as a lung cancer survivor. It has asked and answered questions I have wanted to ask or know the answers to. Thank you so much!”

	Online registration for the CLRC Cancer Rights Conferences in Washington, DC, and Ann Arbor, Michigan, is available at 

	For more information about the services provided by the CLRC, please visit 

Advocacy Spotlight

The Cancer Legal Resource Center (CLRC) is a national, joint program of the Disability Rights Legal Center and Loyola Law School Los Angeles.

Cancer Legal Resource Center

Interventions to reduce the pain of port access should be considered, especially in patients who have a low pain threshold. Several types of anesthetics are available including topical, injectable, and nonpharmacological methods. Studies on the use of these interventions are limited to peripheral IV access and the pediatric population. Caution should be used with topical anesthetic sprays (eg, ethyl chloride) over the port access area, as frequent use to access a port can be a cause of skin breakdown over the port access site.

	For all patients with implanted ports, an assessment of pain issues and pain tolerance in relation to noncoring needle insertion should be performed. While many patients experience minimal discomfort and desire no additional intervention, some do. Options for anesthetics, such as topical lidocaine 2.5% and prilocaine 2.5% cream (EMLA® cream), should be considered. As a home care nurse, if no anesthetic cream is available, I have successfully used ice to numb the area for a few minutes prior to skin preparation and port access.

Lisa A. Gorski, RN, MS, HHCNS-BC, CRNI, FAAN

	We use topical anesthetics frequently (eg, EMLA® cream) and apply them 1 hour prior to non-coring needle insertion. We place a transparent dressing over the area where the anesthetic cream has been applied and clean the anesthetic cream off prior to using an antiseptic and accessing the implanted port.

	Oncology and Hematology Clinical Nurse Specialist

 Sidney Kimmel Comprehensive Cancer Center

	Offering a topical anesthetic when accessing implanted ports is an important option for some patients. Minimally, patients should be aware of the option as part of the informed consent process (ie, being informed of alternative approaches to care). That said, there are times that the use of an anesthetic cream is impractical. For example, if the chemotherapy is being delivered by continuous infusion (eg, >24 hours, >96 hours, etc), using a topical anesthetic would require the therapy to stop for the period of time between removing the old non-coring needle and the time needed for the numbing agent to take effect, which is sometimes 30 to 45 minutes.

	Minimally, patients should be aware of the option as part of the informed consent process (ie, being informed of alternative approaches to care). ”

	Some things to consider when deciding to offer a topical anesthetic prior to non-coring needle insertion include: (1) how the anesthetic is administered (injected intradermal anesthetics may increase the risk of infection from the additional needle sticks); (2) when an anesthetic cream needs to be applied (because it may take an hour for the full numbing effect to occur, patient scheduling needs to be considered, and patients may need to apply the cream prior to arrival); and (3) what will be administered (eg, the duration of action of topical anesthetic creams is ≥2 hours, and if vesicants are administered, the anesthetic action of the cream may diminish the patient’s sensation of discomfort around the non-coring needle site). Topical anesthetic sprays (eg, ethyl chloride) need to be used with caution. They should be sprayed at a distance of 3 to 9 inches for 4 to 10 seconds or until the skin just turns white. The length of spray time depends on the skin’s sensitivity to cold and factors such as blood flow and skin depth. Over-spraying increases the risk of skin alteration (redness, irritation). Other considerations are the short duration of action (the anesthetic effect lasts up to 1 minute) and that ethyl chloride spray is not a sterile product (although it has passed the Microbial Limit Test in accordance with the United States Pharmacopeia).

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

	If you have a clinical question for which evidence is lacking or controversial that you would like our experts to address, please submit it to 

What would you do

Oncology nurses provide their expert opinions to answer the question of whether a topical anesthetic should be used to prior to noncoring needle insertion.

What Would You Do: Should Topical Anesthetics be Used to Numb the Skin Overlying an Implanted Port Prior to Noncoring Needle Insertion?

 The number of cancer survivors in the United States has quadrupled since 1971, making it imperative for healthcare professionals to identify and address the needs of this burgeoning population.

	“As survival rates improve, cancer patients, whose needs were once totally focused on treatment, now need a way to return to their lives,” said Diva Thielvoldt, RN, MSN, CRNP, the nurse practitioner who manages survivorship plans at the University of Texas Medical Branch in Galveston.

	Survivors who think they’re out of the woods medically are often stunned to learn about late effects and long-term effects of some cancer drugs and therapies, including tooth decay, infertility, incontinence, osteoporosis, Hodgkin lymphoma, heart problems, shortness of breath, sexual dysfunction, kidney failure, liver problems, skin sensitivity, hypothyroidism, memory loss, and second primary cancers.

	“They are not thinking that’s coming out down the road,” Thielvoldt said. “Ten years down the road, you have this 55-year-old man who is going to go on a date and tell his girlfriend he wears diapers.”

	To guide and support patients in their transition to survivorship, cancer treatment programs have started to create survivorship care plans.

		Diva Thielvoldt, RN, MSN, CRNP, University of Texas Medical Branch

	Survivorship care plans are personal and portable records of patients’ cancer histories bundled with pointers for healthy post-treatment lives.

	Survivorship plans, rooted in a 2005 recommendation from the Institute of Medicine, serve as road maps for patients exiting oncology care and settling into life as cancer survivors.

		Inform all cancer survivors about essential screenings and recommended lifestyle changes.

		Let patients and primary care providers know about the long-term and late effects of cancers.

		Direct patients to resources they may need to deal with legal, workplace, or psychosocial issues associated with their cancers.

		Carolyn Vachani, MSN, RN, AOCN®, LIVESTRONG and Penn Medicine

	Bridging the Gap Between Physicians and Patients

	Survivorship care plans can be a highly beneficial tool for the millions of survivors who transition to their primary care providers for post-cancer care. A 2009 survey

 showed nearly half of responding primary care providers felt unprepared to evaluate the late effects of adult cancer survivors’ treatments. Further, more than half of the primary care providers in a recent survey

 rated the segue from oncology to primary care as “fair” or “poor.” Most said they were unsure how long testing for recurrence should continue and how frequently it should be performed.

	“We’re getting questions from all over the country about long-term effects,” said Carolyn Vachani, MSN, RN, AOCN®, project leader on Penn Medicine’s LIVESTRONG Care Plan. “Unfortunately, when they’re being followed by a primary care physician, the physician may not know that something can be an effect of their treatment. So nobody who is really in tune with long-term effects is watching them.”

	“Everybody knows that when you ask patients about the transition to survivorship care they say, ‘Everything is great when I get my treatment, but then I’m sort of left out there,’” said Sandhya Pruthi, MD, PhD, associate professor of medicine at the Mayo Clinic in Rochester, Minnesota, and a researcher with the North Central Cancer Treatment Group in Rochester.

	Fifteen percent of primary care physicians say missed care is often or always an issue, according to the Survey of Physician Attitudes Regarding the Care of Cancer Survivors

	Survivorship care plans address these concerns by optimizing care coordination among primary care physicians, patients, and oncology care teams. The plans clearly define the roles and responsibilities of the various healthcare professionals and supply each of them with an accurate account of the patient’s cancer history and specific guidelines for follow-up care. The information ensures each caregiver is equipped to optimize patient care during the transition to survivorship and beyond.

		Stacie Corcoran, RN, MS, AOCNS®, Memorial Sloan- Kettering Cancer Center

	Oncology nurses who have developed survivorship care plans say they fit perfectly with the profession because nurses have always been patient educators.

	“Nurses have always been in the lead in empowering their patients. Now even more so,” said Thielvoldt. “Our objective for our patients after treatment is to help them maximize what they have, which is life.”

	Nurses are also highly adept at compiling the documents needed to create survivorship care plans. Advanced practice nurses often comb through chicken-scratch records from several hospitals to glean details of tumors and past treatments.

	In my cancer center, we developed a survivorship care plan template based on some existing models and configured it to fit the needs of our patients and institution. But with more and more care plan resources now available, it is not necessary to reinvent the wheel.

	The American Society of Clinical Oncology has templates for creating care plans that can be printed right off their website, filled in by providers, and then shared with patients.

	The American Cancer Society has a care plan builder for patients to complete with the help of their oncology care providers. It gives step-by-step instructions on creating a summary of treatment, as well as assists patients to clarify concerns that are lingering after treatment is over.

	The National Cancer Institute has a fact sheet that can assist institutions and healthcare providers create a customized care plan for their patients. The 

 fact sheet lists the essential information to include in a survivorship care plan.

	In my experience as a survivorship nurse navigator, reviewing the care plan can be an overwhelming task for the patient. I find that I am most successful in meeting the needs of my patients when I focus in on their immediate concerns and address these first. I point out in summary all that is included in their care plan, and why this is important for them to have in their records, encouraging them to share their care plans with their primary care physicians. Often, a patient is so consumed with fatigue, pain, fear, and the like that our time is spent working on resolving these issues and making the appropriate referrals. I always remind myself that the goal for our patients is the best possible quality of life after treatment.

	“Nurse practitioners are phenomenal in scouring through old charts coming sometimes from multiple institutions,” says Stacie Corcoran, RN, MS, AOCNS®, nurse leader for the survivorship program at Memorial Sloan- Kettering Cancer Center.

	Nurses will also look to patients to fill in the information gaps. “Our hope is, going forward, people will get this information at the time they’ve finished treatment, and they’ll have it. There’s a push among patients to kind of take ownership of their own information. There’s less of that ‘Let the doctor handle it,’ [mentality],” according to Vachani.

	Although survivorship care plans sound like an instant win-win for patients and providers, only 27% of oncology nurses say their cancer centers provide the plans, according to an Oncology Nursing Society (ONS) survey.

 Insurers do not currently reimburse for the plans, so assembling them drains resources without covering the cost.

	“I think if it were reimbursed, it would make it more feasible for practices to get it done,” said Margaret Irwin, RN, MN, PhD, research associate with ONS. “It’s my understanding, from talking to people, that it’s very time-consuming to pull together all of that information. In a very busy practice that is trying to financially survive, that’s a difficulty for them. And, even if it were reimbursed, we still have shortages of doctors and advanced practice nurses. Reimbursing something helps, but it’s not necessarily going to create more people.”

		Building a cancer survivorship care plan from scratch is a tall order. You must include specifics—diagnostic tests, tumor site and stage and grade, hormonal status, marker information, treatment dates, surgeries, chemotherapy, radiotherapy, transplants, hormonal therapy, gene therapy, agents used, treatment regimen, dosage, any clinical trials, treatment response, toxicities experienced, plus contact information for providers and treating institutions.

		And that’s just the history portion of the plan.

		Plans also outline what patients must do to stay healthy and what screenings primary care providers should prescribe. They list the possible long-term and late effects of cancer treatment so patients and providers can recognize them as cancer-connected. Without the backstory, foggy memory due to radiation might throw up red flags about early-onset Alzheimer disease. Resources that deal with the effects cancer treatment could have on relationships, sexual functioning, finances, work, and parenting are also included in the plans.

		The plans, which didn’t exist 6 years ago, are being fashioned at cancer centers around the world. Some are 1-page long, while others comprise dozens. A few are universally designed, but many are institution-centric— engineered to sync with the specific facilities electronic records system and tailored to meet the needs of local patients and health professionals.

		Diva Thielvoldt, RN, MSN, CRNP, a nurse practitioner in the University of Texas Medical Branch, is fashioning a plan that will work from cities to rural settings, and she hopes to eventually have plans that can be used by survivors whose first language is Spanish or Vietnamese.

				NursingCenter.com offers a 1-page plan at 

Cover Story

The number of cancer survivors in the United States has quadrupled since 1971, making it imperative for healthcare professionals to identify and address the needs of this burgeoning population.

Survivorship Care Plans: Should Every Patient Have One?

	Celebration at the end of cancer treatment is often premature. For example, a newly minted survivor, having lived through the trauma of a diagnosis of breast cancer, a modified radical bilateral mastectomy, 8 rounds of dose-dense chemotherapy, and 35 days of three-field radiation cannot yet fathom how she will reenter her previous life. Fatigue, chemobrain, and pain cause further despair. On top of all this, her treatment is not actually over. Decisions remain concerning ovarian ablation, hormone therapy, and coping with the postmenopausal symptoms that will likely follow.

	Hair now coming in as a fuzzy halo, GI discomfort left over from chemo, and third-degree burns developing from the inside-out over her left breast and axilla, it is with great difficulty that she smiles for the seemingly endless rounds of celebration from her caregivers on her last day of radiation treatment. Behind her brave smile are deep concerns about her low energy level, memory problems, and the possibility of recurrence. She ponders heartbreaking questions, such as, “Will I be able to play with my children as I once did?”

	Survivorship care plans offer patients such as this one a detailed course of action to regain mobility, strength, and confidence. Using the recommendations of the 2005 Institute of Medicine (IOM) report 

From Cancer Patient to Cancer Survivor: Lost in Transition

, care plans address patients’ immediate and long-term needs, facilitating their physical and psychosocial recovery.

	In my clinical practice setting, patients within 7 days of completing treatment are given the 

City of Hope Quality of Life Assessment for Cancer Survivors

, which is based on the 4 domains of quality of life: Physical, Psychological, Social, and Spiritual. Patient responses are then used to create a survivorship plan. The plan includes interventions focusing on areas in which the patient is experiencing the most difficulty.

	Once the plan is created, patients meet with the Survivorship Nurse Navigator for an education session. In addition to the recommendations in the IOM report, specific interventions for side effects such as fatigue, pain, concentration difficulties, sexual dysfunction, and anxiety are discussed. Regaining stamina and strength through exercise, improving sexual function, coping with depression, and overcoming fear of recurrence are just some of the commonly discussed quality-of-life issues with specific interventions and referrals our patients receive. The forum also encourages patients to ask questions that they had not considered when talking with their physicians.

	In my clinical experience, I have observed that patients receive a tremendous benefit from having a care plan serve as a guide to recovery and continued wellness. ”

	Patients are often referred by their managing care team to physical therapy, nutritional counseling, social services, and community cancer organizations for additional support. That being said, not all of our patients need this type of detail and are thus discharged from treatment accordingly.

	Survivorship Study Misses Bigger Picture

	As with all cancer treatment initiatives, clinical studies of survivorship care plans can provide valuable insight. However, it is important to assess the results of these studies with the proper perspective. A study presented by Grunfeld et al at ASCO 2011 suggested that survivorship care plans do not improve outcomes for patients with breast cancer. The results did not surprise me because the study involved early-stage breast cancer patients who, in my practice, often need the least intervention after treatment. Drawing a conclusion applicable to all cancer patients based on this cohort is a disservice to those patients who are experiencing the acute side effects of treatment.

	In light of the ASCO study’s results, I am relieved that beginning in 2012, screening survivors for distress (Standard 3.2) and providing a treatment summary and survivorship care plan (Standard 3.3) will be the standard of care for cancer programs seeking accreditation from the Commission on Cancer of the American College of Surgeons. This will ensure that all patients get the support they need at the end of treatment.

	In my experience, I have observed that patients receive a tremendous benefit from using a care plan as a guide to recovery and continued wellness. Not all patients need the interventions, but for those who do, a care plan is an essential part of their recovery after treatment.

	I know this first-hand as both a Survivorship Nurse Navigator and the cancer survivor discussed above.

	Please join me as we continue to discuss survivorhsip care. E-mail me your survivorship questions and examples of best practices at 

 and we will do our best to provide a variety of responses from our colleagues in the field.

Celebration at the end of cancer treatment is often premature.

Treatment Ends, but the Need for Care Continues

Executive Director, President, and Co-founder

National Coalition of Oncology Nurse Navigators

	Increasing numbers of cancer treatment programs striving for improvements in efficiency and adherence to care look to nurses as a key element to improved patient outcomes. Over the past 20 years, the concept of patient navigation through a complex and fragmented healthcare system has evolved. Oncology Nurse Navigators (ONNs) have emerged from the field of oncology nursing to answer the call within the healthcare system for patient navigation for all cancer types. The ONN is the clinical professional with the knowledge and skills necessary to assess patient needs and make referrals to appropriate resources and services.

	The role of the ONN is evolving as the healthcare delivery system continues to undergo major changes. Internet access and other advances in technology have opened new avenues for patients and family members to educate themselves and gain resource information. This increased capacity to access information has improved care, reduced delays in treatment, and produced an overwhelming amount of resources and information to be interpreted and managed.

	Consistent with national trends, the National Coalition of Oncology Nurse Navigators (NCONN) is developing a healthcare ONN model that provides education and support for the professional nurse navigator. ONNs are the clinical professionals with the knowledge and skills necessary to support the cancer patient, the family, and other support persons throughout the entire cancer experience, from point of entry (which is variable) through treatment and survivorship.

	Apart from the roles of a licensed nurse, the ONN needs to develop competencies to integrate the roles of healthcare promoter, educator, counselor, care coordinator, case manager, researcher, and patient advocate.”

	The ONN is responsible for coordination of care across the continuum. By accompanying the patient through every aspect of his or her cancer journey, the ONN is best positioned to advocate for and provide guidance to patients and their families. The ONN is able to ensure access to the information necessary for the patient to make the best possible decisions about treatment, providing the counsel and advice to improve the patient’s quality of life, and ultimately, improving patient satisfaction. Furthermore, the ONN helps decrease healthcare costs through appropriate utilization of healthcare resources.

	Apart from the roles of a licensed nurse, the ONN needs to develop competencies to integrate the roles of healthcare promoter, educator, counselor, care coordinator, case manager, researcher, and patient advocate. Hence, education programs for preparing ONNs must ensure that professional nurse navigators are equipped with the essential competencies that enable them to fulfill these roles competently and ethically.

	One of the initial items NCONN addressed when it started was developing the first set of core competencies for the ONN. The core competencies developed serve the following purposes:

		To frame the philosophy of oncology nurse navigation based on accepted nursing practice.

		To define the professional role of oncology nurse navigation and the competencies required to successfully fulfill the role.

		To lead the development of curriculum and navigation models that prepare ONNs to guide and support cancer patients in a safe and ethical manner.

		To inform healthcare employers and the public of what they may expect from an ONN upon entry to practice.

		To educate currently practicing ONNs to further develop and/or establish a successful navigation program regardless of practice size, type, or geographical location.

	To receive a copy of the ONN Core Competencies, contact NCONN at 

	Hopkins J, Mumber MP. Patient navigation through the cancer care continuum: an overview. J Oncol Pract. 2009;5(4):150-152.

Nurse Navigators

Increasing numbers of cancer treatment programs striving for improvements in efficiency and adherence to care look to nurses as a key element to improved patient outcomes.

Core Competencies for the Oncology Nurse Navigator

		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

	Christopher R. Friese, PhD, RN, AOCN®, assistant professor, University of Michigan School of Nursing, has had a long-standing interest in extending his research on quality of cancer care to the community, where an estimated 85% of cancer care is delivered. He and his research team began by conducting focus groups with staff nurses and learned that many outpatient oncology practices did not have consistent processes in place to keep nurses safe, and that nurses were at risk for unintentional chemotherapy exposure. To learn more about this risk, Friese sought input from a nursing expert in safe handling of hazardous drugs, Martha Polovich, PhD, RN, AOCN®, associate director of Clinical Practice, Duke Oncology Network, and conducted a study to identify the organizational structures and processes of care that are associated with an increased risk of unintentional chemotherapy exposure.

	Friese’s research team sent a survey to 1339 outpatient oncology nurses in one state and received 402 responses (response rate, 30.5%). There were minimal demographic differences between respondents and nonrespondents, and 16.9% of the respondents reported that their skin or eyes had been unintentionally exposed to chemotherapy in the previous year. The likelihood of exposure decreased when nurses reported adequate staffing levels and resources, and when they reported that chemotherapy doses were verified by 2 nurses either frequently or very frequently.

	When asked if the study findings surprised him, Friese said, “We anticipated that unintentional exposure occurred, but the rate of reported exposure was higher than we thought. Sadly, the reported rate of 17% is consistent with a finding from a study published in the 1980s. We also were surprised how strong the relationship between nursing workloads and exposure was.”

	Polovich was also surprised by the reported skin or eye exposure. “Given that nurses are inclined to underestimate their hazardous drug exposure, it is very concerning. Since no information was collected about precaution use, it’s not possible to determine the cause(s) of the exposure. The adverse effects of exposure make this a serious issue.”

	Friese has launched a second study to better understand when, where, and why exposure occurs, and what personal protective equipment (PPE) elements and precautions were in place at the time. “This will help us identify the ‘danger zones’ to nurses. Another intriguing area is how clinicians are handling patient excreta. The direct effect of exposure to patient waste is unclear but is ripe for research,” he noted.

	The influence of staffing on chemotherapy exposure in Friese’s study is similar to what Polovich found in her soon-to-be published study on precaution use: As the number of patients per day increased, the use of precautions decreased. “Certainly, lower precaution use can result in increased exposure,” she noted. “Since the nurse-patient ratio seems to be related to worker safety as well as patient safety, we need to determine what is the most appropriate staffing for nurses administering chemotherapy. We need to develop and validate acuity systems for outpatient infusion centers. For inpatient chemotherapy, nurses need to have assignments adjusted or be relieved of other patient care when they are responsible for chemotherapy administration. No nurse should be too busy to use safe handling precautions. Managers of chemotherapy nurses have to understand that and plan for it.”

	Sadly, the reported rate of 17% is consistent with a finding from a study published in the 1980s. We also were surprised how strong the relationship between nursing workloads and exposure was. ”

—Christopher R. Friese, PhD, RN, AOCN®

	Polovich also noted that an interesting finding of Friese’s study is that chemotherapy exposure was less likely to occur in organizations where nurses perform a double-check before chemotherapy administration. “It’s not just ‘slowing down’ the process, as some have suggested. To me, it represents the influence of the safety culture in the facility. Organizations with a better safety climate do not separate patient safety from staff safety—they value both. In my study, a positive workplace safety climate was related to higher hazardous drug precaution use. Employers share the responsibility for safe practices, whether it’s adherence to the ASCO/ONS Chemotherapy Safety Standards or the NIOSH, OSHA, or ONS hazardous drugs safe-handling guidelines.”

	Friese hopes that his study helps nurses articulate health and safety risks to their employers, and that oncology nurses lead the way in standardizing the process by which chemotherapy is prepared, administered, handled, and disposed. He noted that “increased attention to the workplace is likely to not only confer benefits to patients, but to the clinicians who care for them as well.”

	Friese CR, Himes-Ferris L, Frasier MN, et al. Structures and processes of care in ambulatory oncology settings and nurse-reported exposure to chemotherapy [published online ahead of print August 16, 2011]. 

Nurse's Notes

Study finds 17% of oncology nurses in outpatient infusion clinic are exposed to chemotherapy drugs.

October 2011