	With approximately 80% to 90% of multiple myeloma patients developing osteolytic bone lesions at some point during the course of their disease, it is important for oncologists to monitor these patients, and to design and administer appropriate bone health treatments at the earliest stages, in an effort to prevent or minimize the effects of skeletal-related events (SREs).

	For many years, the standard method of assessing the extent of bone disease in multiple myeloma patients has been a skeletal survey, which consists of a series of x-rays across the whole skeletal system that can detect “punched out” lesions caused by multiple myeloma. This method detects approximately 80% of cases of myeloma that have metastasized to the bone.

	However, not only does this method not catch every case of bone disease, it only detects them if lytic bone disease has caused at least 30% of the trabecular bone to be lost. Likewise, it is not sensitive enough to assess how patients respond to therapies designed to prevent SREs or maintain bone mass.

	The use of combination PET-CT scans is one method of following a patient after he or she has been prescribed a medication used to mitigate bone disease.

	“A PET-CT can give you a real-time image of whether the disease is progressing,” said David S. Siegel, MD, PhD, Chief of the Division of Multiple Myeloma at John Theurer Cancer Center in Hackensack, New Jersey.

	CT scans utilize a higher level of radiation, so they are not typically used for screening. However, in combination, PET-CT scans are able to detect small lesions that could not have been detected through whole-body x-rays. Because the lesions detected through PET-CT scans are small, there is a higher probability of obtaining false-positive results.

	MRI allows for the assessment of myeloma involvement in bone marrow. It has been shown to have greater sensitivity than radiographs when used to detect asymptomatic bone disease.

	“An MRI is a great way of looking at whether the myeloma is diffuse and has presented itself in other parts of the bone structure,” Siegel said.

	Siegel noted that one method being investigated is the use of PET and MRI scans together. Additionally, PET scans have become much more sensitive as different isotopes, such as (18)F-fluoride, have been utilized, making multiple myeloma lesions easier to identify.

 in August compared the accuracy of (18) F-fluorodeoxyglucose (FDG) PET-CT scans with contrast- enhanced MRI for multiple myeloma. These are the two most sensitive imaging techniques currently available for patients with multiple myeloma. The study was a retrospective analysis of 210 PET-CT and 210 MRI studies of multiple myeloma patients.

	PET-CT scans had a greater impact on downstaging: 11 of 62 patients who received PET-CT scans (17.7%) had their disease down-staged compared with only 1 patient who had an MRI (1.6%). Additionally, in 27 of 40 patients (67.5%) who achieved good or complete clinical response to therapies, the normalization of findings was faster for PET-CT scans than for MRI (

	In 90 patients who received the scans for followup, however, MRI was better at detecting disease recurrence. Of those 90 patients, 10 of the patients presented with clinical recurrence. MRI was able to detect active lesions in 8 of the 10 patients (80.0%) compared with 5 patients by PET-CT scans (50.0%).

	“The skeletal survey is still the standard,” Siegel said. “However, PET and MRI scans are extremely useful and have improved tremendously over time and are a necessary part of following up with these patients.”

	Early Interviews, Follow-up Scans Crucial

	Bone disease is so prevalent in multiple myeloma patients that the time to begin examining a myeloma patient’s bones is right at baseline, according to Elizabeth Bilotti, MSN, BSN, APN-C, who works in the myeloma division at John Theurer Cancer Center in Hackensack, New Jersey. She said that it is important to interview the patient at baseline to see if he or she reports being symptomatic, complains of bone pain, or exhibits any other signs that might indicate bone disease, in addition to a skeletal survey. “All of that needs to be part of the work-up when trying to provide a diagnosis.”

	While early diagnostic tests are important, Bilotti said that follow-up tests utilizing PET-CT scans or MRI scans are crucial when it comes to following the course of disease.

	“A PET-CT can be a great way of determining whether a patient is developing plasmacytoma,” Bilotti said, indicating that plasmacytoma denotes a lesion that appears to be an isolated form of myeloma, and therefore has not yet spread throughout the bone.

	Bilotti cautioned that a combination PET-CT scan is not perfect. Even when a head-to-toe PET scan is performed, there is a high probability of obtaining a false-positive.

	This is why Bilotti recommends employing multiple imaging methods in every patient when available. In Bilotti’s experience, a MRI scan is not as good a method for looking at the bone, but it’s a better method of looking at the marrow and soft tissue in general. For example, a MRI scan is better for looking at the spinal cord and determining whether the disease has caused any cord compression.

	“If a patient is experiencing cord compression fractures, MRIs are a good way of identifying and following those fractures,” Bilotti said.

	Drugs like zoledronic acid are recommended by several treatment guidelines as a method of addressing these bone issues, but Bilotti said that nothing on the market as of yet reverses the bone damage caused by multiple myeloma.

	“When looking at these images, we’re not expecting to see a reversal of the lesions or the fractures,” Bilotti said. “We’re looking to compare these lesions to baseline and make sure that their progression is being kept to a minimum.”

	Spinnato P, Bazzocchi A, Brioli A, et al. Contrast enhanced MRI and (18)F-FDG PET-CT in the assessment of multiple myeloma: a comparison of results in different phases of the disease. [published online ahead of print August 23, 2012]. 

Articles

Feature Story

It is important for oncologists to monitor, design, and administer appropriate bone health treatments at the earliest stages for the 80% to 90% of patients with multiple myeloma who develop osteolytic bone lesions.

Detecting Bone Disease in Multiple Myeloma Patients

	Linda Weisenberger knows that leaders in the public and private sectors are working to resolve America’s drug shortages.

	But the promise of a solution somewhere on the horizon isn’t enough for the registered nurse, who navigates supply shortages every day as clinical coordinator of the cancer program at Genesee Cancer and Blood Treatment Center in Flint, Michigan. In the 22-chair private chemotherapy infusion clinic, Weisenberger, RN, OCN, and her colleagues frequently must carry out treatment plans without the medications best suited to patients’ curative or palliative care.

	“We’ve had to change the protocols recommended in NCCN [National Comprehensive Cancer Network] guidelines and by our doctors because we were unable to get a drug, which results in us giving our patients archaic treatment,” she said.

	Due to drug unavailability, Weisenberger has given medications to be taken at home that should have been administered intravenously, increasing the risk of dosing mistakes. She has given a cancer drug to the lucky patients who showed up when it was available, then had none for those who came the next day.

	Weisenberger has watched patients endure nausea, vomiting, and diarrhea when drugs added to their chemotherapy infusions could have spared them those symptoms. She’s seen substitutes for standard-of-care drugs discontinued in favor of even less effective medications due to side effects, and she’s seen patients dropped or excluded from clinical trials because protocol drugs were unavailable.

	And she’s not alone. Joni Lutman, MSN, FNP-C, a nurse practitioner at James Cancer Hospital at Ohio State Medical Center, has also seen patients suffer because of drug shortages.

	Lutman, who treats head and neck cancers, said shortages of liquid antibiotics and pain medications have been difficult for her patients, who, after treatment with chemotherapy, often can’t swallow. As alternatives, she said, patients sometimes must take solid drugs that have been crushed.

	If you ask Weisenberger, the situation isn’t improving much.

	“Every day,” she said, “I hear of a drug I have to stock up on right now, because in a couple of months we won’t be able to get it.”

	While certain oncology drugs were previously hard to find, it’s now ancillary drugs, like furosemide (Lasix), atropine, potassium, and mannitol, that are in short supply, leaving some patients in danger of side effects including kidney problems, Weisenberger noted.

	To work around the shortages, Weisenberger has been involved in borrowing between hospitals and clinics. She’s also spent lots of early mornings calling distributors of desired drugs.

	“The manufacturer might send them five cases, and if I wanted them, I’d have to be one of the first people to ask for it,” she said.

	And that’s just one of many inconveniences associated with drug shortages, the nurses agreed.

	While drugs in shortage are often inexpensive generics, Weisenberger pointed out, brand-name alternatives can cost much more—and sometimes insurers refuse to pay.

	“Normally they’ll pay it after an appeal,” she said, “but it’s the physician who initially pays for that drug, and that means he might not get paid back for a year-and-a-half.”

	Lutman added that many insurers refuse to approve drugs without preauthorization, and in some cases require patients to try a different medication before the one their doctor has prescribed.

	“They want to try the least costly alternative first,” she said, “but with antiemetics, for example, we prefer to give a drug specific to fighting cancer side effects, like Zofran (odansetron). Cheaper alternatives might make the patient sleepy, and if he’s already on pain medication, we don’t want to make him more tired.”

	Overall, Lutman said, the process of finding alternatives for drugs in short supply is “time consuming. It takes away from other things, like seeing the patient.”

The promise of a solution somewhere on the horizon for America's drug shortages isn't enough for the registered nurse who navigates shortages every day.

Drug Shortages Frustrate Nurses and Jeopardize Patient Care

	Cancer geneticists from around the globe will agree on one thing: A thorough personal and family history is the key to determining which patients are candidates for genetic counseling and testing. This information can unlock the secret of why a particular family has been afflicted with many cancer diagnoses, often at young ages. Having this information may make it possible for many other family members to finally know their own cancer risks, have the cancer surveillance they need, and reduce their risks of ever developing the cancers seen in the family. There is no greater gift to give a family.

	Oncology nurses are perfectly poised to elicit a thorough cancer family history. They know their patients well, see them for multiple visits over an extended period of time, and often hear about their family members and fears that other loved ones will someday develop cancer.

	These are the secrets to taking a thorough family history:

	1) Collect information on 4 generations of relatives

		This includes at least brothers, sisters, parents, children, grandparents, aunts, uncles, and cousins. If the patient has information on more distantly related relatives, great! Take that information as well.

		Document how these relatives are related to your patient and each other. For example, is this a maternal or paternal aunt? A full sibling or half-sibling through the father? A pedigree is the easiest and most efficient way to capture this sometimes complicated information.

		For individuals who have not had cancer, document their current ages or ages/causes of death. In a family history of ovarian cancer, document whether unaffected family members have ever had their ovaries removed. In a family history of colon cancer, document colonoscopy findings (or lack thereof) on unaffected family members.

The family medical pedigree is one of the most valuable gifts a parent can leave for children and grandchildren.

	2) Elicit information from the maternal and paternal sides of the family

	Far too many patients (and providers) still believe that you can only inherit breast and ovarian cancer risk from your mother, or prostate cancer risk from your father. Both men and women can carry mutations in these genes, and we can all pass these mutations on to both sons and daughters.

	3) Gather information about each person with cancer

	Ask your patient to research for each family member with cancer:

		Pathology, when possible. This is becoming more and more important because different tumor pathology can lead to different genetic syndromes and risks. For example, lobular breast cancer can be seen in families with gastric cancer due to a CDH1 mutation. Triple-negative breast cancers indicate a higher risk of a 

		Whether the person has had genetic testing. If yes, obtain a copy of those test results.

	4) Inquire about related cancers and findings in the family

	For example, in a family with multiple cases of breast cancer, be sure to ask if anyone has had ovarian, pancreatic, thyroid, or gastric cancer. In a family with a history of colon cancer, ask if anyone has had multiple polyposis, ovarian or uterine cancer, or sebaceous adenomas or carcinomas. Each of these findings can lead to a different genetic syndrome.

	What about the patient who says she doesn’t know her family history? Advise the patient to do some research:

		Contact a family elder (eg, grandparent, great-aunt, or great-uncle) for information.

		Reach out to the cousins you haven’t spoken to in 20 years to get an update on their cancer history.

		Track down estranged relatives or relatives you’ve never met using Facebook and other social networking tools.

		Nail down a diagnosis by obtaining death certificates, which are public record.

		Request pathology reports on your own diagnosis, or on other family members with their signed permission (or that of next of kin).

	More often than not, this research will yield a more useful family history.

	This family medical pedigree is one of the most valuable gifts a parent can leave for children and grandchildren. A copy of this pedigree should go in a safe deposit box with other essential family documents and is an investment in the health of future generations.

	The oncology nurse can make a huge difference by encouraging patients to do the research necessary to pull this family history together.

	Ellen T. Matloff, MS, CGC, is a certified genetic counselor and director of Cancer Genetic Counseling at Yale Cancer Center, New Haven, Connecticut.

Genetic Counseling

A thorough personal and family history is the key to determining which patients are candidates for genetic counseling and testing.

The Secret to Success: Eliciting a Thorough Cancer Family History

	Over the past several decades, many advances have offered new treatment options to cancer patients and added to the ever increasing numbers of survivors. With advances in treatment, however, therapies have become more complex and have increased the long-term side effects. Several studies have documented that cancer and its treatment creates or aggravates psychosocial distress, while unresolved physical and practical problems can also add to the distress of patients attempting to complete their treatment and recovery.

	Oncology nurses know that unresolved distress can lead to additional problems, such as nonadherence to therapy

 Addressing distress concerns in patients with cancer can have a positive impact in reducing distress and improving quality of life.

	In 1999, the National Comprehensive Cancer Network (NCCN) established a panel to investigate and evaluate the issues that contribute to distress in patients with cancer. That same year they developed the first set of guidelines to screen for and treat distress in patients with cancer. The term distress was chosen because it didn’t have the stigma associated with a psychiatric diagnosis and also encompassed recognition of the physical, social, emotional, and practical issues that can contribute to anxiety and distress.

 as “a multifactorial, unpleasant, emotional experience of a psychological (cognitive, behavioral, emotional), social and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears, to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis.”

	In 2008, the need for addressing psychosocial issues and distress in cancer patients became more prominent with the publication of the Institute of Medicine (IOM) report, “Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs.”

 Most recently, the American College of Surgeons Commission on Cancer incorporated a standard for distress screening into its cancer program accreditation.

	Many factors contribute to distress in patients with cancer. Several studies have evaluated the incidence of distress with a meta-analysis indicating that up to 47% of patients have a significant level of distress and, overall, approximately 30%-40% of patients have some combination of mood disorder.

 It has been further noted that the incidence of major depression increases with increasing levels of physical disability, advanced illness, and pain.

 Physical symptoms can also contribute to distress, with fatigue, sleep disturbance, and pain being the most commonly reported physical symptoms.

	More recently, distress research has evaluated the impact of caregiver burden on the distress level of the patient with cancer. The stress of caregiving can negatively impact the ability of the caregiver to provide for the needs of the patient, thereby adding to the distress of the patient with cancer.

	Distress screening should occur on the first visit and at interval visits as clinically indicated throughout the patient’s cancer journey, particularly at times when increased distress is likely. Distress for patients can include external or internal sources, such as cognitive, social, and spiritual components. Distress can present at any point during the cancer diagnosis and treatment.

	Patients are often hesitant about discussing stressful events, whether it is their own cancer diagnosis, stressful family dynamics, financial issues, or even their lack of knowledge or low education level. The NCCN guideline has incorporated a list of psychosocial distress characteristics. This list identifies patients at increased risk for distress, as well as periods of increased vulnerability for patients. Patient characteristics that increase the risk for distress can include psychiatric disorders, substance abuse disorders, poor social support, inadequate resources, communication barriers, uncontrolled symptoms, and severe comorbid illnesses.

 The NCCN further identifies periods of increased vulnerability, which can include staging and work-up, when the patient is informed of the diagnosis, when a change in treatment is indicated because of disease progression, recurrence of disease, or advancing cancer to end-of-life care, as well as discharge from the hospital, transition to survivorship, and ongoing medical surveillance. This reinforces the importance of screening on a periodic basis, because once a patient is diagnosed with cancer, he or she will likely continue to face these periods of vulnerability.

	Barriers to care can impact quality of life and increase distress in patients with cancer. Screening can identify many of these barriers so that appropriate management can be implemented; however, frequently there are barriers to providing the support indicated.

	Barriers to screening for distress can arise from the healthcare team, the healthcare system, or from the patient. Patient barriers include psychiatric disorders and the stigma that may be attached to psychological issues, substance abuse, cognitive impairment, depression with or without suicide attempt, communication/language barriers, financial limitations, insurance problems, work or transportation issues, and cultural or spiritual concerns. Patients may also be hesitant to discuss their concerns with healthcare team members for various reasons. Healthcare team/system barriers include time constraints in oncology offices, lack of knowledge on how to screen for and manage distress issues, scheduling delays, lack of community resources or lack of knowledge regarding resources, inappropriate use of specialized staff, technological factors, communication/ language barriers, and other uncontrolled factors. The time and effort required to fill out and then discuss the results of the screening tool can feel overwhelming and exhausting to patients who are already feeling fatigued.

	Regardless of the numerous barriers to distress screening, the patient needs to be assessed and evaluated both psychologically and physically in order to be treated appropriately throughout the cancer journey.

		Karen Masino, MS, CNP, ACNP-BC, AOCNP, RN,

	There are multiple evidence-based screening tools in what appears to be a trend toward the use of a simple instrument such as the distress thermometer and the distress problem checklist.

 This tool has been validated to indicate distress in patients if the score is 5 or higher on the distress thermometer.

	Other widely used tools include the Hospital Anxiety and Distress Scale (HADS)

 and instruments that have been developed for specific disease sites such as breast, as well as automated touch-screen computerized technology that appears to be at least as well accepted as a paper version.

 It is beyond the scope of this article to discuss these tools in depth. The reader is referred to Carlson et al

 for a more in-depth discussion of various tools. The ideal screening tool should be brief, and scoring results should be both simple and efficient. The tool used may evaluate distress experienced in the past day, week, or within the patient’s lifetime. Stressors, once identified, should be monitored, documented, and treated promptly.

	Building a Distress Screening and Management Program

	Screening for distress is considered only the first step in identifying factors that contribute to a poorer quality of life. Just as important as completing the screening, is having processes in place to address the issues that confront patients.

	Selecting a multidisciplinary team is recommended for implementing and monitoring distress management. While the primary oncology team— which typically consists at a minimum of an oncology physician and oncology nurses&mdash;can address many patient concerns, it is important to include other disciplines and community resources to provide the full spectrum of services patients may require; these may include therapists, social workers, nutrition services, chaplaincy services, psychiatric and mental health services, palliative care and hospice services, as well as community agencies providing support groups and assistance with practical problems such as transportation and financial concerns. Many facilities already have representation from these areas on their cancer committees. Formalizing these resources into a subcommittee of this group may be one approach in developing a distress management program.

	The team should determine the tool and the process that will be implemented to develop a distress screening and management program. The tool selected may be determined by the staff appointed to do the screening. In some facilities, a social worker may be designated to meet with the patient or may review the screening and make referrals to other professionals. In other facilities, the screening may be done as part of a routine office visit with the physician and staff, in which case a very fast tool such as the distress thermometer8 may be more appropriate for screening. The process needs to identify how the screening will be completed and at what points it will occur.

	Good communication must be a priority in addressing concerns of patients. Acknowledging the patient’s concerns and providing adequate time to explore the patient’s issues can help to develop a trusting relationship between the patient and the healthcare team and set the stage for a positive relationship in the future.

	Each facility or physician practice needs to identify available resources and staff to address and manage distress issues. It is important to emphasize that all services do not have to be housed within a facility; resources that are available by referral or connecting with a community resource also need to be included. Networking with community groups and developing partnerships with outside organizations is strongly recommended. The listing of resources should be formalized and disseminated throughout the institution and treatment facilities.

	Since distress issues can affect patients throughout the cancer trajectory, it is necessary to have the resources to address all of the issues that can cause or exacerbate distress, from diagnosis through to survivorship and into end-of-life care. Carlson et al

 outline key points for successful implementation of a distress screening program:

		Adequate time needs to be allocated to lay the groundwork.

		Gain support of hospital administrators and clinic coordinators prior to implementing screening.

		Offer appropriate training for staff involved in screening, providing services, and processing reports. Assess available support services to address psychosocial needs and physical problems to determine if additional services are needed.

		Triage guidelines and algorithms can be helpful.

		Perform ongoing evaluation, and be sure to determine whether the screening program addresses needs of the medically frail, minority, and underserved populations and those with language barriers.

	Role of the Oncology Nurse Navigator in Distress Screening

	The oncology nurse navigator (ONN) is in an ideal position to be involved in screening for distress, as well as providing management of distress issues, supporting patients as they progress through the cancer trajectory. The ONN functions as an advocate for patients, explaining disease and treatment options and linking patients with resources that will enable them to complete their treatment and maintain or improve their quality of life. The ONN also is a primary point of contact to facilitate communication and act as a liaison with the healthcare team on behalf of the patient.

	The intervention of an ONN has demonstrated a positive impact on distress scores of selected groups of patients.

 Since unresolved distress has been implicated in increased medical costs and, possibly, shortened survival,

 the impact of an ONN in lowering a patient’s distress level is an area that warrants further study.

	Nurse navigators can evaluate distress levels in patients and communicate these concerns to the healthcare team. Oncology nurses have been consistently involved in providing education to patients regarding their disease process and treatment, side-effect management, and in providing support.

	Because of the many sources of distress, the ONN can also provide interventions to help guide patients on managing their symptoms, as well as providing links to resources that can address their distress issues and help them with their coping skills.

	ONNs are key stakeholders in developing distress screening and management programs within their facilities and are active participants in interventions to provide support and improve the quality of life of patients with cancer.

			Partridge AH, Wang PS, Winer EP, Avorn J. Nonadherence to adjuvant tamoxifen therapy in women with primary breast cancer. 

			DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: metaâ€analysis of the effects of anxiety and depression on patient adherence. 

			Bultz B, Holland J. Emotional distresss in patients with cancer: the sixth vital sign. 

			Brown KW, Levy AR, Rosberger Z, Edgar L. Psychological distress and cancer survival: a follow-up 10 years after diagnosis. 

			Adler N, Page A. Institute of Medicine: Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: National Academies Press; 2008.

			Jacobsen PB, Jim HS. Psychosocial interventions for anxiety and depression in adult cancer patients: achievements and challenges. CA: 

			Breitbart W, Poppito S, Rosenfeld, B, et al. Pilot randomized controlled trial of individual meaningâ€centered psychotherapy for patients with advanced cancer. 

			National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology for Distress Management V.3.2012. 

http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf

Nurse Navigators

Cancer and its treatment creates or aggravates psychosocial distress, while unresolved physical and practical problems can also add to the distress of patients attempting to complete their treatment and recovery.

Screening and Management: Distress and the Nurse Navigator, Part II

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

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

		Louisiana State Health Sciences Center in New Orleans, Louisiana

	Providing oncology care is in itself intense and challenging, and the ongoing shortage of oncology drugs has made clinical practice even more challenging as we deal with the shortage on a very personal level. We’ve had national drug shortages for years, but it has only been fairly recently that we—and our patients&mdash;have really felt the impact.

	We all remember the first time or two that we heard that an oncology drug was in short supply. It was a time of disbelief that left us wondering how a drug that had been around for ages was now unavailable. Sometimes we were fortunate to find someplace willing to share its stock of a needed drug, but as time passed, pharmacy shelves were depleted and some oncology drugs were not available anywhere. This led to the beginning of the painful decision era, as prescribers had to consider drug substitution or dropping a drug from a treatment regimen. These decisions, in turn, created a lot of anxiety for our patients and put us in the unenviable position of telling our patients that we don’t know if the treatment will be as effective with a substituted drug or without the needed drug.

	Patients and their families also have had a hard time grasping the idea that a needed oncology drug is simply not available. As one patient said, “I can’t believe this is happening in 2012, here in the USA, in the land of plenty.” I think we all felt a sense of frustration and helplessness, because aside from “calling our member of Congress” (a common recommendation at the start of the shortage), there really was little we could do personally to resolve the shortage.

	It’s intensely personal to care for patients who are expecting established, evidence-based cancer treatment, but have their hopes dashed when needed drugs are available one day and unavailable the next.

	It was, and still is, intensely personal to care for patients who are expecting established, evidence-based cancer treatment, but have their hopes dashed when needed drugs are available one day and unavailable the next. The drug shortage has made chess players out of us, as we try to anticipate when a drug will again be available. We’re also now clairvoyants and chemists as we contemplate drug substitutions and predict how patients might respond. In the end, the oncology drug shortage has radically changed our practice and how well (or how inadequately) our patients have been treated.

	We’re now hearing accounts of patients who have died, or have had disease recurrence or progression that have been attributed to the oncology drug shortage. These stories have received a great deal of media attention, and they should. The drug shortage now has the faces of real people, making the situation more personal to government officials, manufacturers, and all who have contributed to the drug shortage. It’s been personal to those of us who are clinicians from the start.

	Although reports of active drug shortages declined 14% between 2011 and 2012, 211 drugs remain unavailable or in short supply. In order to track the drug supply, the private and nonprofit sectors have created online information resources, such as the American Society of Health-System Pharmacists website (www.ashp.org/ shortages) and the FDA drug shortage website (

http://www.fda.gov/Drugs/DrugSafety/DrugShortages/default.htm

). Organizations, such as the advocacy organization Fight Colorectal Cancer (

), are providing information, such as “What to do when your doc is out of 5-FU” to inform and empower patients.

	Manufacturing problems are believed to be responsible for more than half of all drug shortages, and manufacturers are now required to alert the FDA 6 months in advance when drugs are discontinued or supply disruption is anticipated. In February 2012, the FDA also approved the importation of some drugs, such as Lipodox from the Indian manufacturer Sun Pharma Global. Hopefully, a combination of awareness, legislation, and action will put an end to the oncology drug shortage, and we will never again have to tell patients that lifesaving drugs are not available.

Nurse's Notes

Providing oncology care is in itself intense and challenging, and the ongoing shortage of oncology drugs has made clinical practice even more challenging as we deal with the shortage on a very personal level.

September 2012

Detecting Bone Disease in Multiple Myeloma Patients

Drug Shortages Frustrate Nurses and Jeopardize Patient Care

The Secret to Success: Eliciting a Thorough Cancer Family History

Screening and Management: Distress and the Nurse Navigator, Part II

The Oncology Drug Shortage: At Practice Level, Shortages Become Personal and Painful