In the journey of a patient with breast cancer, there are many touchpoints where nurses can make a significant difference in the quality of their experience. From educating patients about their surgical options to supporting them with postoperative care to providing them with tools and information to have a successful recovery, nurses are there.

This month’s cover story highlights some of the latest 

. Penny Banks, MSN, BSN, RN, who is featured on the cover, explains that newer procedures improve on older techniques by avoiding cutting muscles and by using a patient’s own tissue from other parts of their body to recreate the breast. Several other nurses share what they do to support patients through their reconstruction journeys.

Two feature stories highlight finalists from this year’s 

, were nominated by their colleagues for their innovative practices. You will read about the compassion, expertise, and helpfulness each demonstrates to deserve the recognition.

In her column, Lisa Schulmeister, MN, RN, FAAN, explains the importance and the recommended procedures for i

dentifying immune-related adverse events and reporting them

 to the Food and Drug Administration. In our Fast Facts for the Frontline column, the question of the nurse’s role in addressing patients’ 

 is addressed. The Professionally Speaking column addresses the pros and cons of nurses wearing 

In news from our nursing school partners, a group of researchers at Smilow Cancer Hospital at Yale-New Haven successfully tested a postsurgery protocol that bypassed the surgical intensive care unit for patients with head and neck cancer who underwent free tissue flaps and composite resections. Their efforts reduced length of stay and drastically cut the rate of readmissions. Also, Michigan State University offers an update on what is included in the multigene panel test for breast cancer and why.

The October Continuing Education articles cover the gamut from a new technology in breast cancer biopsies to developments in brain, gastric, and ovarian cancers, and lymphoma. 

As always, we hope you find this issue engaging and informative and that it enhances your practice.

Articles

From the Chairman

This letter from the Chairman and CEO of Oncology Nursing News gives an overview of the contents of the October 2018 print issue of the magazine.

Rebuilding the Breast

Mary Alison Smania, DNP, FNP-BC, AGN-BC, FAANP, is a board-certified family nurse practitioner and advanced genetics nurse and assistant professor, Health Programs, at Michigan State University College of Nursing in East Lansing.

 has rapidly advanced in the past decade. 

 used to look at only 1 or 2 genes, but now panel, or multigene, testing is available.

With estimates of approximately 252,000 new breast cancer diagnoses every year and 3.5 million breast cancer survivors,

 oncology nurses should assess whether patients are candidates for genetic testing for both their family members and themselves.

As essential members of the healthcare team, oncology nurses can identify patients who may be at risk for a genetic mutation and can significantly improve care for these patients and their families. Up to 10% of those diagnosed with breast cancer may have a genetic mutation.

The 2 most common genetic mutations associated with breast and ovarian cancer, 

2, were identified almost 20 years ago. Since then, research and improvements in genetic testing have found mutations in other genes that are associated with breast cancer.

Next-generation sequencing has increased the ability to iden&shy;tify several genes in a short period. Although these genetic mutations are much less common and do not seem to increase risk as much as 

, it is still important to iden&shy;tify the risk and potential impact on patients and families.

Many testing facilities offer multigene panels for breast cancer risk. Below are some of the genes that are included in multigene panels for breast cancer:

Helps repair damaged DNA. Inheriting 1 mutated 

gene increases the risk of breast cancer 2- to 4-fold).

Acts as a tumor suppressor gene. Mutations can increase breast cancer risk.

Works to repair DNA. There is insufficient evidence that 

increases breast cancer risk, but inheriting 1 mutated 

gene is associated with a higher risk of ovarian cancer, so it may be included in a multigene panel.

Makes a protein that helps cells bind together to form tissue. Women with a 

mutation have a 39% to 52% life&shy;time risk of invasive lobular breast cancer.

Provides instructions to the body for making a protein that stops tumor growth. 

mutation can increase the risks for breast, colon, and prostate cancer.

Forms in the MRN complex that helps repair DNA damage in cells. Mutations can weaken the immune system.

Acts as a tumor suppressor protein. A mutation can cause an increased risk of breast cancer.

Provides instructions to make a protein that works with the BRCA2 protein to repair damaged DNA and stop tumor growth. It is a 

mutation and some studies show this mutation increases breast cancer risk 5 to 9 times higher than the average.

Helps regulate cell growth and causes Cowden syn&shy;drome, a rare disorder in which people have a higher risk of both benign and cancerous breast tumors, as well as growths in the digestive tract, thyroid, uterus, and ovaries. The lifetime breast cancer risk for women with a 

mutation causes Peutz-Jeghers syndrome, a rare disorder in which people tend to develop a hamartomatous polyp, mostly in the small intestine, but also in the stomach and colon. Such a polyp increases the risk of gastrointestinal, breast, lung, and ovarian cancers. Those with this mutation may also develop freckling around the eyes and nose and around and inside the mouth.

Provides instructions to the body for making a protein that stops tumor growth and causes Li-Fraumeni syndrome, a disorder that causes people to develop soft tissue cancers at a young age. People with this rare syndrome have a higher than average risk of breast cancer and several other cancers.

WHO SHOULD ONCOLOGY NURSES REFER FOR TESTING? 

Genetic testing can help patients understand and make import&shy;ant risk-reducing surgical decisions or consider therapies indi&shy;cated for those diagnosed with metastatic breast cancer, such as PARP inhibitor therapy. In addition, genetic testing for the patient can help with determining if other family members should also have testing and take steps to decrease their risk. Consider referring patients with 1 or more of the following:

personal or family history of breast cancer diagnosed before age 50, ovarian cancer, triple-negative breast cancer, or bilateral breast cancer

cancers in a family in addition to breast, such as prostate, melanoma, pancreatic, stomach, uterine, thyroid, colon, and sarcoma

Assessing patients for breast cancer risk begins with gathering their personal and family histories. Determine if the patient is at risk, and if they are, refer them for testing. Along with evalua&shy;tion for risk, it is essential to explain to the patient why genetic testing can guide treatment, potentially saving the lives of the patient and their family members.

American Cancer Society. Breast cancer facts and figures 2017-2018. ACS website. cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2017-2018.pdf. Published 2017. Accessed September 7, 2018.

Bernstein, JL, WECAREStudy Collaborative Group, Concanon, P. ATM, radiation and risk of second primary breast cancer

 2017 Oct;93(10):1121-1127. doi: 10.1080/09553002.2017. 

NCCN Clinical Practice Guidelines: Genetic/Familial High-Risk Assessment: Breast and Ovarian Version 2.2019. NCCN website. nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf. Published July 30, 2018. Accessed September 7, 2018.

Cybulski C, Wokolorczyk D, Jakubowska A, Huzarski T, Byrski T, Gronwal J, et al. (2011).  Risk of breast cancer in women with a 

 mutation with and without a family history of breast cancer. J Clin Oncol. 2011 Oct 1;29(28):3747-52. doi: 10.1200/JCO.2010.34.0778

 mutation and risk of prostate cancer: a systematic review and meta-analysis. Int J Clin Exp Med. 2015 Sep 15;8(9):15708-15. 

Slavin, TP, Neill-Swiller, M, Solomon I, Nehoray B, Rybak C, Blazer KR, Weitzel JN (2015). Clinical application of multigene panels: Challenges of next-generation counseling and cancer risk management. Front Oncol. 2015 Dec 2;5:271. doi: 10.3389/fonc.2015.00271.

Antonis AC, Casadei S, Heikkinen T, Barrowdale D, Pylkas K, Roberts J et al. Breast-cancer risk in families with mutations i ALB2. 

, 2014 371(6) 497-506. doi:  10.1056/NEJMoa1400382.

Partner Perspectives

This article reviews the types of genes included in multigene panels for breast cancer, and the risks associated with those genes.

Understanding Multigene Testing for Breast Cancer

Investigators are hopeful that idasanutlin, a novel small molecule that targets the MDM2 protein, can improve the efficacy of chemotherapy in patients with relapsed/refractory acute myeloid leukemia (AML). This agent is being tested in combination with cytarabine, which is commonly used as a first or second salvage therapy in this patient population, in the international phase III MIRROS clinical trial (NCT02545283).

Idasanutlin inhibits the MDM2 protein, which degrades p53, a known tumor growth suppressor, said Marina Y. Konopleva, MD, PhD, professor in the Department of Leukemia at The University of Texas MD Anderson Cancer Center in Houston. The drug binds to MDM2 to prevent the inter&shy;action between the 2 proteins, resulting in the ongoing activation of p53 and tumor-cell apoptosis.1

The primary endpoint in the MIRROS trial is overall survival (OS) and will be assessed in a subset of the patient population with the gene 

wild-type, with OS in the overall population as a secondary endpoint. Assessing the 

wild-type population as the primary endpoint is important because idasanutlin’s mechanism of action depends on p53, which is encoded by 

About 440 participants are expected to join the trial (NCT02545283). They will be randomized 2:1, idasanutlin with cytarabine versus cytar&shy;abine with placebo. In the experimental arm, 300 mg of idasanutlin will be given orally twice a day in a 28-day treatment cycle (cycle 1). Responding participants may continue with 300 mg once daily (cycles 2 and 3) for 5 consecutive days each 28-day treatment cycle. One g/m2 IV infusion of cytarabine will be given for 5 consecutive days each 28-day treatment cycle.

The trial is currently enrolling patients with relapsed/refractory AML who have experienced 1 or 2 relapses. They also must have received no more than 2 prior induction regimens, and 1 or both must have included cytarabine with an anthracycline.

Konopleva is hopeful that if idasanutlin and cytarabine yield a higher response rate than cytarabine alone in the MIRROS study, the combi&shy;nation could become a standard of care for patients with AML with the 

wild-type gene as first or second salvage therapy.

Idasanutlin. Genentech website. biooncology.com/pipeline-molecules/idasanutlin. html. Accessed June 4, 2018.

A version of this article was originally published by 

Potency of CAR T-Cell Therapy Investigated in Relapsed/Refractory MCL

Clinical Trials in Progress

Investigators are hopeful that idasanutlin, a novel small molecule that targets the MDM2 protein, is being tested in combination with cytarabine in the international phase III MIRROS clinical trial (NCT02545283) to see if omprove the efficacy of chemotherapy in patients with relapsed/refractory acute myeloid leukemia (AML).
 

MDM2 Inhibitor May Improve Response in Acute Myeloid Leukemia

Cara M. Henderson, RN, BSN, CMSRN, is patient service manager, Smilow Cancer Hospital, Yale New Haven Health, New Haven, Connecticut.

 is director of nursing, Patient Services, Smilow Cancer Hospital, Yale New Haven Health, New Haven, Connecticut.

At Smilow Cancer Hospital, a National Cancer Institute—designated comprehensive cancer center, patients undergoing free tissue flaps and composite resec&shy;tions for cancers of the head and neck historically had a 24- to 48-hour postoperative stay in the surgical intensive care unit (SICU). After that time, they were transferred to the surgical oncology inpatient unit for the remainder of the postopera&shy;tive period. Surgical oncology is a 28-bed unit specializing in postoperative care for patients who have undergone oncologic surgery. Although head and neck reconstruction is an extensive surgical procedure, many of the patients require intensive care unit (ICU)-level care solely for frequent monitoring of vital signs and hourly assessment of flap perfusion. Therefore, specialized nursing care on the surgical oncology unit created an opportu&shy;nity to bypass the SICU and transition patients directly from the post–anesthesia care unit (PACU) to the surgical oncology unit.

The goal of this practice change was to reduce length of stay, postoperative complications, and readmission rates of patients with head and neck cancer undergoing free flap surgery. Bypass&shy;ing the ICU could potentially decrease the length of stay for these patients by mobilizing them earlier. A review of the lit&shy;erature strongly suggested that early postoperative ambulation improves patient outcomes and reduces length of stay.

An interdisciplinary team was convened to establish criteria for patient selection. Patients with minimal medical comorbid&shy;ities undergoing free tissue flap reconstructive surgery and/or composite resection were chosen as candidates to bypass the SICU and receive all postoperative care on the surgical oncology unit. A standard of nursing care was established by creating a pathway for each of the postoperative days, to outline the expected patient milestones. Order sets and electronic health record optimizations were executed prior to implementation in order to standardize care. The reconstructive surgeon educated unit staff on the free tissue flap pathway, including postoper&shy;ative care. Nurses observed patient care in the SICU prior to caring for their first patient. A standardized handoff from PACU to surgical oncology was created and education provided to the PACU prior to the first patient in May of 2015.

Data collected over a 2-year period included length of stay and postoperative complications, such as return to the ICU, return to the operating room, and rate of readmission. Three time peri&shy;ods—pre-pathway, early pathway (first year after implementa&shy;tion), and the current state&mdash;were measured. The length of stay was reduced by 3 hospital days and ICU utilization decreased by 94%. We also experienced tremendous reduction in the rate of readmissions: from 16% to 3%. Reduc&shy;tion in length of stay has a significant impact on direct care costs and ensures appropriate ICU bed utilization for patients who require life-sustaining measures. Shortened length of stay reduces the incidence of hospital-acquired infections and improves patient outcomes. Overall, the change in practice improved the teamwork on the unit as well as interdisci&shy;plinary communication. Future development of guidelines for patient selection to bypass the SICU will be based on data review of those patients who required ICU transfer from surgical oncology or returned to the operating room.

We are now standardizing the tracheostomy policy across the system and implementing a process for safe transport of patients with arti&shy;ficial airways throughout the hospital, whether that be from unit to unit or from unit to procedural area. A task force created a travel kit for emergent patient events during travel, and the concept is now being modeled at the institutional level.

This initiative not only demonstrated a reduction in length of stay, ICU utilization, and rate of readmission, but it also improved the interdisciplinary teams’ approach to patient care. Interdisciplinary collaboration improved teamwork on the unit, in particular among physicians and nurses. The physician team reported that it relies heavily on the nurses’ assessment of the patient’s condition and have included them on morning rounds to provide input on a patient’s overall progress. As patient acu&shy;ity increases and the hospital continues to care for patients’ complex healthcare needs, there are opportunities to model this approach within other patient populations.

Oliveria RA, Guatura GMGBDS, Peniche ACG, Costa ALS, Poveda VB. An integrative review of postoperative accelerated recovery protocols. 

2017;106(4):324-330.e5. doi: 10.1016/j.aorn.2017.08.005.

Smilow Cancer Hospital tested sending patients directly from the post–anesthesia care unit (PACU) to the surgical oncology unit after head and neck surgery to reduce length of stay, postoperative complications, and readmission rates of patients.

Bypassing the SICU May Improve Patient Outcomes

Axicabtagene ciloleucel (axi-cel; Yescarta), an anti-CD19 chimeric antigen receptor (CAR) T-cell therapy, was previ&shy;ously approved for the treatment of patients with certain types of large B-cell lymphoma who had not responded to other therapies. This success led investigators to test the treatment in patients with relapsed or refractory mantle cell lymphoma (R/R MCL), a rare B-cell non-Hod&shy;gkin lymphoma that affects 4200 new patients in the United States each year.

Patients with MCL frequently fail several therapy options and often do not live as long as a year. Their average survival is about 8 months.

Results of the ZUMA-1 phase I/ II trial (NCT02348216) presented at the 2017 AACR Annual Meeting showed an objective response rate of 82%, with a complete response (CR) rate of 54%; after 8.7 months of follow-up, 39% of patients remained in CR.

 In phase II of the ZUMA-1 clinical trial, axi-cel demonstrated promising activity in patients with large B-cell lymphomas. Updated long-term results showed that axi-cel induced an objective response rate of 82%, with a CR rate of 58%.

The value of axi-cel in treating R/R MCL will be tested in the multi&shy;center phase II ZUMA-2 clinical trial (NCT02601313).

Patients will receive a fixed dosage of fludarabine and cyclophosphamide— conditioning chemotherapy daily, followed by a single infusion of axi-cel administered intravenously. The primary endpoint of the trial is the overall response rate, with duration of response, best objective response, and progression-free survival as sec&shy;ondary endpoints.

The phase II Zuma-2 trial will enroll about 130 patients with an ECOG performance score of 0 or 1 who have received no more than 5 prior therapies. Eligible participants must have received an anthracycline- or bendamustine-containing chemothe-rapy, anti-CD20 monoclonal anti&shy;body therapy, and Bruton’s tyrosine kinase inhibitor therapy with ibru&shy;tinib (Imbruvica) or acalabrutinib (Calquence).

MCL is an aggressive and often incurable disease, and much hope and expectation rests on axi-cel for success in this trial. Results from ZUMA-2 could be available in 2019. 

Mantle cell lymphoma facts. Leukemia & Lymphoma Society website. lls.org/sites/default/files/file_assets/mantlecelllymphoma.pdf. Updated November 2014. Accessed August 1, 2018.

Locke FL, Neelapu SS, Bartlett NL, et al. Primary results from ZUMA-1: a pivotal trial of axicabtagene ciloleucel (Axi-cel; KTE-C19) in patients with refractory aggressive non-Hodgkin lymphoma (NHL). Presented at: 2017 AACR Annual Meeting; April 1-5, 2017; Washington, DC. Abstract CT019. cancerres.aacrjournals.org/content/77/13_Supplement/CT019.

Neelapu SS, Locke FL, Bartlett NL, et al. Long-term follow-up ZUMA-1: a pivotal trial of axicabtagene ciloleucel (axi-cel; KTE-C19) in patients with refractory aggressive non-Hodgkin lymphoma (NHL). Presented at: ASH Annual Meeting and Exposition; December 9-12, 2017; Atlanta, GA. Abstract 578. bloodjournal.org/content/130/Suppl_1/578?sso-checked=true.

The value of axicabtagene ciloleucel (axi-cel; Yescarta), an anti-CD19 chimeric antigen receptor (CAR) T-cell therapy,  in treating R/R MCL will be tested in the multi&shy;center phase II ZUMA-2 clinical trial (NCT02601313).

Investigating the Potency of CAR T-Cell Therapy in Relapsed/Refractory MCL

A cancer diagnosis can leave your patient with many questions. Sitting in a hospital room or infusion center for long hours might give them time to reflect on their diagnosis, life, and place in the universe. They may turn to you for support and answers as they meditate on their mortality. Is there a place for spiritual care in oncology nursing?

, RN, OCN, CBCN. Baldwin has been a nurse for 35 years, and most of that time has centered around oncology, hospice, quality improvement, and long-term care. Eleven years ago, she became a pastor, and today, she is chaplain of the Mitchell Cancer Institute in Mobile, Alabama.

In her current role, Baldwin brings her passions for nursing and as a spiritual counselor together to help patients and nurses. She describes spirituality as an integral part of any holistic nursing assessment, making it an essential component of active treatment and survivorship.

But for many nurses, engaging in these conversations can be uncomfortable. You may even question if this is indeed a part of your role. In a recent interview, Baldwin explained the difference between spirituality and religion and a few easy ways to handle these difficult conversations.

SPIRITUALITY VERSUS RELIGION IN NURSING CARE

There is no agreed-upon definition of spiritual care in nursing.

 Spirituality is personal and varies from one person to the next.

 defines spirituality as a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationships to self, family, others, community, society, nature, and the significant or sacred.

 Spirituality is expressed through beliefs, values, traditions, and practices.

Baldwin simplifies this definition. In her view, “spirituality is a personal interpretation of the soul.”

How does this differ from religion? Baldwin described religion as a community of faith. It is structured and often defined by rituals. The online Merriam-Webster Dictionary defines religion as the service and worship of God or the supernatural.

 It is a personal set or institutional system of religious attitudes, beliefs, and practices.

Religion and spirituality can occur together or separately, so it’s essential you first understand both. Then you can begin to practice a few ways to bridge these conversations easily or know when it is time to request help from a spiritual counselor.

Baldwin stressed the importance of knowing and understanding your own beliefs before engaging in conversations with your patients. One study that examined how nurses assist patients with spirituality found that the personality and background of the nurses influence how they approach these conversations.

Your comfort level with your spirituality is connected to how you view patients in illness.

 Your comfort zone should include your spiritual and religious beliefs, practices, and limitations. If prayer is outside of your comfort level, that’s okay, Baldwin says. You can still offer spiritual care to your patients by being present.

Nurses aren’t expected to know all the answers. You often don’t need any answers to meet the patient where they are on their spiritual journey.

Active listening is one of the best skills to use when dealing with difficult conversations. Listen to understand, not to respond. Acknowledge your patient’s courage in talking about their spiritual needs and thoughts. Baldwin also suggested using a technique like reflection, where you merely state back to the patient what they just said, to keep the conversation going. “Be open to [patients’] beliefs and allow them to talk freely,” Baldwin says. “A quiet moment of silence or simple prayer may be all that’s needed.”

When engaging in conversations around spirituality, be careful not to overstep the bounds of your professional responsibility. Always speak with compassion and honesty.

If the conversation goes in a direction outside of your abilities or inclinations, it is okay to let the patient know that you would like to call in a spiritual counselor to be sure that their needs are met.

KNOW WHEN TO TURN TO A SPIRITUAL COUNSELOR

“Even pastors need to lean on others for help,” said Baldwin. She described fellow spiritual leaders as a necessity. Keep a list of religious leaders in your area and call on them for spiritual needs outside of your comfort zone and abilities. If your health system has a chaplain, use their services. And you can always ask the patient if they have a pastor, rabbi, or another spiritual counselor they would like you to call.

To increase your spiritual literacy, read books and journal articles. Understand different religions and spiritual beliefs. Talk about spiritual care practices in in-services or nurse meetings. Have a chaplain present on common topics.

Nurses deal with life-or-death situations. Your soul connects with others. This makes self-care imperative. “Acknowledge your own beliefs and sadness,” says Baldwin. “Make your physical, emotional, and spiritual health a priority. Nurses are at a high risk for compassion fatigue, which can lead to depression, anxiety, and exhaustion. You must care for your own spiritual needs to be able to provide needed spiritual care to others.”

Offering spiritual care doesn’t have to be difficult. Prayers can be simple and words don’t have to be fancy. Be present and connect to the spiritual needs of your patients and care for yourself, too. And if you don’t feel comfortable in the role, call in an expert.

Melissa Mills, BSN, RN, CCM, MHA is a freelance healthcare writer and the owner of MakingSpace.company. She has been a registered nurse for 20 years and is passionate about case management, nursing leadership, and finding the right care for patients in every setting.

Giske T, Cone P. Discerning the healing path — how nurses assist patient spirituality in diverse health care settings. 

2015;24(19-20):2926-2935. doi: 10.1111/jocn.12907.

Hughes Rev BP, DeGregory C, Elk R, Graham D, Hall Rev EJ, Ressallat J. Spiritual care and nursing: a nurse’s contribution and practice. HealthCare Chaplaincy Network website. healthcarechaplaincy.org/docs/about/nurses_spiritual_care_white_paper_3_3_2017.pdf. Published March 2017. Accessed September 6, 2018.

Religion. Merriam-Webster Dictionary website. merriam-webster.com/dictionary/religion. Accessed September 6, 2018.

Fast Facts for the Frontline

How should oncology nurses deal with patients' spiritual needs?

Difficult Conversations: Dealing with the Spiritual Needs of Patients with Cancer

Ketamine, typically used to kickstart and maintain anesthesia use, could be an option for treating patients with ovarian cancer whose pain is difficult to treat.

“Although the data for ketamine do not include a large number of placebo-controlled trials, there are [findings from] smaller studies suggesting that ketamine may be beneficial when used appropriately for patients with very difficult-to-control pain symptoms,” said Christopher J. Pietras, MD, director of palliative care and assistant clinical professor at the UCLA School of Medicine, in an interview with 

. “These patients would already be on very high doses of opioids and nonopioid adjuvant medicines, like gabapentin,” he added.

® State of the Science Summit™ on Ovarian Cancer, Pietras presented on the possible use of ketamine in palliative care for those with ovarian cancer. He said that while larger studies are needed, in the few that are available, ketamine may be promising. However, it is still too early for a conclusion to be made.

“Therefore, ketamine should only be used in a select group of patients who have uncontrollable pain, despite highly esca&shy;lated opioids and other medications, and in patients who do not have traits that would make them more likely to have [adverse events],” he said. “This includes patients who might feel confused and those who have anxiety, as those are the most ommon [adverse events] with ketamine.”

This was adapted from an article that originally appeared on 

Pietras Presents Pillars of Palliative Care in Ovarian Cancer

Adverse Events Report

Ketamine May Benefit Those With Difficult Pain From Ovarian Cancer

Although many of us are looking forward to the upcoming football season and holidays, they are often tough times for the patients and caregivers who would rather be anywhere than at a medical facility. Nurses, too. Nurses with lots of team spirit may have to miss high school, college, or NFL games. Nurses who have to work during the holidays may dread those shifts and the sacrifice of missing family events. With such mixed emotions, it’s not surprising that nurses might want to wear a team jersey at work or a costume for Halloween, even dress in holiday-themed scrubs. On the flip side, nurses must also consider that reminding patients of the traditions and shared events they are missing due to their cancer may evoke negative emotions.

Is dressing for the season in the workplace inappropriate, insen&shy;sitive, or unprofessional? It may be difficult to determine whether a team jersey, costume, or accessory is appropriate. Before donning that elf costume, ask yourself 3 questions:

Is there any guidance from your human resources team about the dress code in your organization?

Employers usually have a dress code that guides what is appropriate and acceptable in the workplace. Their goal is to establish profes&shy;sionalism, as employees must represent their employers in a posi&shy;tive way. Although it may seem insignificant or trivial, studies show that nursing attire can have a significant impact on patient percep&shy;tion, trust, and the professional-patient relationship.

Most dress codes speak to holiday wear but are not very specific. For example, one organization’s policy states, “During holiday seasons, sweatshirts or sweaters with holiday decor may be worn with department head approval. Holiday wear cannot have dangling decorations.” Interpreting this statement can be challenging. What constitutes a holiday season? Does it include only select holidays like Christmas, Easter, and the Fourth of July? What about other minor holidays, such as St. Patrick’s Day? What about holidays celebrated by certain cultures, such as Chinese New Year? What about days that some consider a holiday, such as Super Bowl Sunday? There is a holiday for almost every day of the year in the United States.

“Holiday wear” can also be an ambiguous term. Does it include costumes or apply to holiday scrubs? What about holiday jewelry or accessories such as cat or bunny ears? Would you consider holiday makeup (eg, green eyeshadow and red lipstick for Christmas) holiday wear? Your definition and your organization’s definition may not be the same, so it is important to check the details of the dress code.

Anything that extends past your person could present a challenge to keep clean and prevent transportation of germs from patient to patient. Take into account how costumes, jewelry, and accessories may interfere with your ability to safely care for a patient. Most poli&shy;cies have very specific details about jewelry worn in the workplace, such as the size of earrings, length of a necklace, or number of rings.

Nurses must always think about transporting germs, especially in the care of patients with cancer. Some areas caring for patients with severe neutropenia, such as hematopoietic cell transplant (HCT) or leukemia units, may take extra precautions to prevent infection. They often have policies about not sharing equipment (eg, stetho&shy;scopes or scales), significantly limiting or eliminating jewelry, and not wearing fake fingernails. They may require nurses to change into scrubs and put on work shoes once they get to work instead of at home. In these areas, holiday wear usually is prohibited.

Be sensitive to how a costume, acces&shy;sory, or even face painting might scare some patients or cause concern to a care&shy;giver. If a patient is taking medications that can cause confusion or hallucina&shy;tions, such as narcotics or antiemetics, or has brain metastasis that alters cognition, a clown face or angel’s halo may cause alarm and distress. In addition, think about how you might feel if you need to provide caregiver support or comfort after a patient takes a turn for the worse or dies.

A nurse’s dress should convey profession&shy;alism and confidence to patients and caregivers at all times. Many nurses claim that patients like it when they dress up or wear holiday scrubs. However, when 200 outpatients and 200 inpatients were asked about this in a research study, holiday scrubs had a mixed ranking (41% supported; 59% did not).

 Perhaps those who vocalize that they like holiday attire represent a smaller portion of your patient population. Also, there may be a population of patients who feel uncomfortable with their nurses wearing certain attire, especially if they are of a different culture or religion. Nurses must consider patient opinion, as today’s healthcare environment is very competi&shy;tive and patient satisfaction matters.

Besides considering your employer’s policy, patient perception, and potential harm, also ask yourself why you want to dress for the holiday. Is it to express your individuality? “Self-expression is great, but not in the work place,” advises Imee Unto, MSN, RN, OCN, vice president/chief nursing officer, Florida Hospital Ocala, Adventist Health System, West Division. Unto is responsible for enforcing the dress code at her organization. “The dress code is in place to define what is acceptable to the organization.”

What do you think about oncology nurses wearing sports team gear and holiday attire to work?

Share your opinions on Twitter with the hashtag

West MM, Wantz D, Campbell P, Rosler G, Troutman D, Muthler C. Contributing to a quality patient experience: applying evidence-based practice to support changes in nursing dress code policies. 

2016;21(1):4. doi: 10.3912/OJIN.Vol21No01Man04.

Professionally Speaking

Is it appropriate for oncology nurses to dress up for occasions or holidays at work?

Dressing for the Season

 agents are receiving expedited approval from the Food and Drug Administration (FDA). The upside of moving these agents from clinical trials to patients so quickly is that patients receive proven life-saving treatment sooner. The danger lurks in the amount of time available to collect data on adverse events (AEs) associated with the agents.

An analysis of new oncology drug approvals from 2012 to 2016 found that 42 of 43 of the FDA-approved drugs were reviewed using at least 1 of the 4 FDA expedited review pathways: breakthrough therapy designation, acceler&shy;ated approval, fast track, and priority review. This trend is expected to continue for the foreseeable future.

In April 2018, the Oncology Nursing Society (ONS) launched the “Recognize It, Report It” campaign to promote reporting of AEs associated with drugs given FDA expedited approval. Immunotherapy clinical trials used well-defined controlled patient populations, and now that these agents are widely administered in community settings, AEs not seen before are occurring. In addition, their management is challenging, especially for those that mimic other AEs. For example, dyspnea and fever often are first associated with pneumonia in a patient receiving cancer treatment; however, in a patient who has received immunotherapy, they could be due to cytokine storm-causing pneumonitis.

In November 2017, the Society for Immunotherapy of Cancer released consensus recommendations for recognizing and managing immune-related AEs. This advice is expan&shy;sive and includes pre-immunotherapy screening guidelines, a systems-based review of possible AEs and their manage&shy;ment, and information about uncommon events and infusion reactions. The recommendations were created as a “living document,” with updates made as new agents and new drug combinations become available.

In February 2018, the American Society of Clinical Oncology, in collaboration with the National Comprehensive Cancer Network, published guidance on management of immune-related AEs in patients treated with immune check&shy;point inhibitor therapy. Their recommendations are based on toxicity grades for specific organ systems.

The ONS “Recognize It, Report It” campaign encourages nurses to document and report immunotherapy-related AEs (IRAEs) to increase the body of knowledge about these events. Nurses are on the frontline of care and often are the first, and sometimes the only, healthcare providers that receive patient reports of infrequently occurring or previously unreported AEs. In addition, nurses usually are the first to observe immu&shy;notherapy-induced infusion reactions.

Therefore, we need to be knowledgeable about 

these AEs, their detection, and their management

. We also need to be aware of the process for reporting AEs to the FDA.

 has a link for voluntarily reporting AEs and another to sign up to receive safety alerts. The reporting process can be completed online using checkboxes and narrative text boxes for deidentified patient information; AE date, description, and outcome; and relevant tests and patient’s medical history. Once completed and submitted, there is an option for viewing, printing, and saving the report as a PDF document. An email is then sent to the person submitting the report to confirm receipt. The FDA reviews the AE reports and evaluates the need for regulatory action, such as updating drug labeling to include information about reported AEs.

In addition to being aware of the FDA AE reporting process, nurses should delineate institutional policies and procedures for reporting. Ideally, an interprofessional (IP) process would be used, with oncologists, oncology nurses, pharmacists, and others involved in the care of patients receiving immuno&shy;therapy discussing AE observations prior to reporting them. One or 2 staff members should be tasked with reporting to help ensure consistency in MedWatch reporting and insti&shy;tutional tracking of AEs. The IP team also should consider publishing a case report or series when previously unreported AEs occur.

IRAEs can occur as these agents are infusing. Symptoms may include fever, rigor, pruritus, hypotension, dyspnea, chest discomfort, rash, angioedema, wheezing, and tachy&shy;cardia, as well as anaphylaxis requiring emergency measures. Nurses need to be prepared to manage these AEs, especially those in which escalation of care and transfer to an emer&shy;gency department or intensive care unit is needed.

IRAEs also may occur after active treatment has completed. Therefore, close patient follow-up is critical. Because little is known about long-term effects and outcomes, nurses have the opportunity to create and implement follow-up assessment criteria. This may include expanding nursing assessment to incorporate specific questions about newly emerging AEs, such as uveal effusion. Patients need to be asked about their vision, floaters, flashing lights, eye redness, light sensitivity, visual distortion, and eye pain. Patients’ eyes can be examined for redness and light sensitivity. As with other immunotherapy-re&shy;lated AEs, prompt detection of ocular AEs is crucial.

Immunotherapy is perhaps the fastest evolving cancer treatment today. However, with progress has come concern about the limited body of knowledge of the AEs associated with these agents. Oncology nurses have a pivotal role in expanding this body of knowledge through the identification, documentation, and reporting of IRAEs. 

Vadola LA, Pond MA, Winter-Vann A, Whitsell R. Faster approvals? Trends in the use of FDA’s expedited approval programs for oncology medications. 

. 2017;(suppl 15):e18270. ascopubs.org/doi/abs/10.1200/JCO.2017.35.15_suppl.e18270.

Fuerst ML. New guidelines outline management of immunotherapy side effects. MedPage Today website. medpagetoday.com/reading-room/asco/immunotherapy/71026. Accessed June 27, 2018. doi: 10.1186/s40425-017-0300-z.

Puzanov I, Diab A, Abdallah K, et al; Society for Immunotherapy of Cancer Toxicity Management Working Group. Managing toxicities associated with immune checkpoint inhibitors: consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group. 

. 2017;5(1):95. 10.1186/s40425-017-0300-z.

Brahmer JR, Lacchetti C, Schneider BJ, et al. Management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: American Society of Clinical Oncology Clinical Practice Guideline. 

. 2018;36(17):1714-1768. doi: 10.200/JCO.2017.77.6385.

Nurse's Notes

Not enough is known about immunotherapy-related adverse events, so it is important to report unusual or
previously unreported ones to the FDA.

Recognize and Report It

Jackie Miller, BSN, RN, OCN, founded Camp Oasis to help offer support to children like her nephew.

Jackie Miller, BSN, RN, OCN, was 8 years into her career when she was tapped to join other handpicked nurses to staff a new unit dedicated to oncology. That was 22 years ago.

“We had identified that we needed this, and it was a core group [of nurses] who were known for helping patients with cancer,” Miller recalls. Because the nurses were all at different skill levels, they also helped each other.

Today, Miller manages the New Jersey Cancer Education and Early Detection Program, which provides health screenings for uninsured residents of Burlington and Camden counties. Overseen by her employer, Virtua Health System, the program operates using state money and grant funding secured through Miller’s efforts. “We have different avenues for different diagnoses, but in most cases, we can provide Medicaid in 24 hours,” she says.

Miller is recognized as someone who can solve a problem when she sees it, which is how Camp Oasis, created for the children of southern New Jersey residents diagnosed with cancer, came about. When Miller’s sister-in-law died from breast cancer a number of years ago, leaving behind a son, the family tried in vain to find support for the boy. “We were at Christmas dinner after she passed away, and we said, ‘This is crazy that there are no resources for families with small children,’” Miller recalls.

Miller envisioned a camp for kids like her nephew, and the idea snowballed. When the Oncology Nursing Society took applications for a special grants project, Miller applied for the funds to create her camp. After she won the grant, she found that her colleagues were poised to get behind her and volunteer to lend a hand. Then, as she began to put the idea into practice, she discovered that the whole community wanted to help.

“When I tried to get space, they ended up donating it. Then, when I went to buy food, they donated it,” she says.

Camp Oasis, which now operates through the Virtua Foundation, provides a magical day for approximately 50 participants. The campers, aged 8 to 18, get picked up in the morning by limousine—a nurse rides along, just in case&mdash;and receive a bandana. After the opening ceremony, the campers are divided into 5 groups based on bandana color.

The children take part in all kinds of activities, including sports, crafts, and a group meeting with social workers who can help the campers open up about their fears. “The social workers are trained in this area to help the children talk to their mom or dad about what is happening,” Miller says.

Last year, a winter camp was added and offered 5 indoor sessions, including playtime with oversized Legos, theater improvisation, and activities at the camp’s indoor waterpark.

At the end of the day, each camper leaves with a folder for their parents that offers information about support groups and provides the phone number for a crisis hotline in case of emotional trouble.

“They are not alone,” Miller says of the children. “By the time they are in the limos going home, the kids are texting each other and getting phone numbers.”

Miller was nominated for a 2018 Extraordinary Healer

 award for Oncology Nursing by her colleague, Randi Solden, BS, RN, OCN, and honored as a finalist by 

Jackie Miller, BSN, RN, OCN, works to provide emotional support for children whose parents have cancer.

October 2018