Whether or not to screen men for prostate cancer is a complicated issue. The cover article of this month’s 

 delves into the arguments for and against prostate-specific antigen testing, and other possible forms of screening. Hear from nurse navigator Frank dela Rama, MSN, RN, CNS, AGN-BC, AOCNS, and survivor and advocate Steve Hentzen on the topic. Steve Shak, MD, co-founder, chief scientific officer, and chief medical officer of Genomic Health, also weighs in on how genomic testing could prevent overtreatment and address underdiagnosis.

 showcases Kathleen Shannon Dorcy, PhD, RN, FAAN, who left a Dominican convent to pursue nursing as her ultimate calling. Shannon Dorcy ministers to patients with cancer, conducts oncology research, and educates nurses around the world. Also in this issue, Editor-in-Chief Lisa Schulmeister shares facts about 

 that nurses should know, before they are asked by their patients, in her “Nurse’s Notes” column.

The “Fast Facts for the Frontline” column explains the benefits of 

, and the “Professionally Speaking” column encourages 

 and their work throughout the year to improve motivation, recruitment, and retention.

Articles in the Clinical Insights section cover trial updates on treatments for lung cancer, kidney cancer, pancreatic cancer, prostate cancer, and hematological malignancies. These articles can serve a dual purpose. They can help you stay abreast of important developments in various areas of the cancer landscape, and they can also help you earn continuing nursing education credit.

We hope you find our content engaging, informative, and helpful to you in your work. These articles will be available on OncNursingNews.com. If you share them on social media, be sure to use the hashtag 

 to reach and connect with a network of oncology nurses like you.

Articles

From the Chairman

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

Prostate Cancer Screening Is Controversial

Amy R. Lipson, PhD, is a senior research associate, and Sara L. Douglas, PhD, RN is the Arline H. & Curtis F. Garvin Professor in Nursing Excellence and assistant dean for research at the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.

Gathering data on goals of care for patients with advanced cancer throughout the illness trajectory, including end-of-life (EOL) goals, can help guide treatment decisions.

 Communication between the health&shy;care team and oncology patients can increase the likelihood that patients receive treatment aligned with their own 

 Accurate assessment is an important aspect of ensuring goals of care align with treatment.

 a team of researchers at Frances Payne Bolton School of Nursing, Case Western Reserve University, sought to exam&shy;ine whether there were differences in resource use at EOL between patients with advanced cancer who identified goals of care focused heavily upon survival versus those who identified goals of care heavily focused on quality of life (QOL). The larger study used a longitudinal descriptive study design and collected data on patients with a diagno&shy;sis of stage 4 gastrointestinal or lung cancers. Data were collected at University Hospitals Seidman Cancer Center in Cleveland, Ohio, every 3 months until the end of the 15-month study period or patient death. Subjects were asked at each time point, “Regarding your care, what is most important to you right now?” (

). Anchors on the 100-point visual analog scale were QOL and survival, with a value of 50 indicating a goal with equal weight given to both domains. Values greater than 50 indicated a goal of care that focused more on survival than QOL. The goals of care data reported here were obtained closest to the sub&shy;ject’s death date.

In this sample of 168 patients with advanced cancer who died during the 15-month study period, the majority of the sample were Caucasian (69.0%) and female (51.8%) and had a diagnosis of gastrointestinal cancer (66.1%), an ECOG performance score of 1 (64.9%), and a mean age of 63.9 (SD = 10.4). Prior to death, 62.9% had an advance directive, 54.2% had received palliative care, and 47.6% had received hospice services. Within 30 days prior to death, 45.5% of the sample had at least 1 visit to the emergency department and 58.1% had at least 1 hospital&shy;ization (with 19% of those being admitted to an intensive care unit).

To further examine how the patients’ goals of care were associated with resource use at EOL, we focused on data in the tails of the goals-of-care scale. We compared resource use between those falling in the group more focused on survival with those more focused on QOL. Those focused more on QOL were more likely to enroll in hospice. All other resource use comparisons (emergency department visits, hospitaliza&shy;tions, intensive care, and palliative care) were not statisti&shy;cally significant. We found that by asking patients a sim&shy;ple question regarding their goals of care, we could assess whether they wanted care that was focused more on survival or QOL. In addition, we found that those who favored goals of care emphasizing QOL had EOL care that was consistent with this goal.

Oncology nurses are in a unique position to talk with patients regarding their goals of care.

 Since the establish&shy;ment of the End-of-Life Nursing Education Consortium in 2000, a collaboration between the American Association of Colleges of Nursing and City of Hope, Duarte, California, to improve palliative care nationwide, momentum has been building to create programs that train nurses to initiate these kinds of discussions with patients. This type of open com&shy;munication can ensure that patient information regarding goals of care is communicated to the healthcare team and, as a result, enhance the likelihood that the patient receives EOL care consistent with their own goals.

You JJ, Fowler RA, Heyland DK; Canadian Researchers at the End of Life Network (CARENET). Just ask: Discussing goals of care with patients in hospital with serious illness. 

. 2014;186(6):425-432. doi:10.1503/ cmaj.121274.

Balogh EP, Ganz PA, Murphy SB, Nass SJ, Ferrell BR, Stovall E. Patient-centered cancer treatment planning: Improving the quality of oncology care. Summary of an Institute of Medicine Workshop. 

2011;16(12):1800-1805. doi:10.1634/theoncologist.2011-0252.

Wittenberg E, Ferrell B, Goldsmith J, Buller H, Neiman T. Nurse communication about goals of care. 

Lipson AR, Douglas SL. Factors influencing care decisions for patients with advanced cancer. 

Partner Perspectives

Researchers exam&shy;ined whether there were differences in resource use at end of life between patients with advanced cancer who identified goals of care focused heavily upon survival versus those who identified goals of care heavily focused on quality of life.

Impact of Goals of Care on Resource Use at End of Life

A novel glutaminase inhibitor, CB-839, may provide a survival benefit in combination with cabozantinib (Cabometyx) by cutting off the energy supply to tumor cells in patients with metastatic renal cell carcinoma (RCC). The combination with CB-839 is being investigated in the randomized phase II CANTATA study (NCT03428217). Investigators hope to improve on the outcomes from cabozantinib alone for patients who have received a tyrosine kinase inhibitor (TKI) or immune checkpoint inhibitor. Cabozantinib is FDA approved as a second-line treatment following prior TKI therapy.

CB-839 is an oral inhibitor of glutaminase, which is essential to the conversion of glutamine, an amino acid, into glutamate, which aids cell signaling. By inhibiting this process, CB-839 deprives tumor cells of energy, the availability of glutamate to the cells decreases, and cell proliferation is blocked.

The inhibition of glutaminase production preferentially reduces tumor cell growth over normal cells due to abnormal tumor metabolism, according to Nizar M. Tannir, MD, professor and deputy chairman in the Department of Genitourinary Medical Oncology at The University of Texas MD Anderson Cancer Center and the lead principal investigator and chair of the steering committee for the CANTATA trial. In addition, the glutamine that builds up in tumor cells as a result of the inhibition of glutaminase helps to fuel T-cell growth, which may increase the tumor-fighting potential of CB-839.

Cabozantinib has synergy with CB-839 because the 2 agents have different mechanisms of action, Tannir said.

 Whereas CB-839 targets tumor cell energy supply and supports T-cell development, cabozantinib inhibits several kinases, including VEGF, MET, and RET, and impairs tumor growth and angiogenesis.

The trial’s primary endpoint is progression-free survival (PFS), which will be assessed by an independent radiology committee. Secondary endpoints include overall survival and PFS as assessed by investigators.

The study is enrolling participants with measurable clear cell RCC who have received 1 or 2 prior lines of therapy, including at least 1 antiangiogenic therapy or nivolumab (Opdivo) combined with ipilimumab (Yervoy). 

1. Glutaminase inhibitor CB-839. NCI Drug Dictionary. National Cancer Institute website. cancer.gov/publications/ dictionaries/cancer-drug/def/glutaminase-inhibitor-cb-839. Accessed June 12, 2018.

2. Tannir NM, Fan AC, Lee RJ, et al. Phase 1 study of glutaminase (GLS) inhibitor CB-839 combined with either evero¬limus (E) or cabozantinib (Cabo) in patients (pts) with clear cell (cc) and papillary (pap) metastatic renal cell cancer (mRCC). 

 2018;36(suppl 6S; abstr 603). meetinglibrary.asco.org/record/156891/abstract.

Clinical Trials in Progress

A novel glutaminase inhibitor, CB-839, may provide a survival benefit in combination with cabozantinib (Cabometyx) by cutting off the energy supply to tumor cells in patients with metastatic renal cell carcinoma (RCC).

Glutaminase Inhibitor That Starves Tumor Cells May Improve Survival in Metastatic RCC

Investigators are evaluating the potential of 

, an oral small molecule inhibitor of RET signaling, to improve outcomes in patients with RET fusion—positive non–small cell 

 (NSCLC), medullary thyroid cancer (MTC), and other tumors with increased RET activity. LOXO-292 is designed to inhibit RET signaling and acquired resistance mechanisms that would limit the effectiveness of this approach.

RET mutations drive tumor proliferation and growth and are particularly common in NSCLC and MTC. However, no singularly targeted agents are currently approved for patients with RET mutation—specific tumors, according to Alexander Drilon, MD, clinical director of the Early Drug Development Service at Memorial Sloan Kettering Cancer Center in New York, New York. “It’s a substantial population,” he said. “RET fusions are found [commonly] in NSCLC, papillary thyroid cancers, and other tumors; RET point mutations are enriched in medullary thyroid cancers.”

Unlike multikinase inhibitors that are approved for NSCLC or MTC, LOXO- 292 is a highly selective potent RET inhibitor that has very few inhibitory effects on other targets. It is also potent in vitro and in vivo against diverse RET fusions and mutations, including the V804M gatekeeper mutation.

The phase I open-label LIBRETTO-001 clinical trial (NCT03157128) is currently testing LOXO-292 in these patient populations to determine the safety and recommended dosage of the drug. The investigators are seeking to enroll approximately 180 participants for this dose-escalation and -expansion study. The primary endpoints are to determine the maximum tolerated dose and the recommended dose for LOXO-292, with secondary endpoints of overall response rate and duration of response.

Patients who are eligible for the trial must be 12 years or older, with an ECOG performance status of 0 to 2. They must have locally advanced or metastatic solid tumors that are refractory or intolerant to standard therapy or that would be unlikely to respond to standard therapy. Most important, they must have a RET alteration.

Drilon AE, Subbiah V, Oxnard GR, et al. LIBRETTO-001: A phase 1 study of LOXO-292, a potent and highly selective RET inhibitor, in patients with RET-altered cancers. 

 2018;36(suppl; abstr 102). meetinglibrary.asco.org/record/161573/abstract.

The phase I open-label LIBRETTO-001 clinical trial is currently testing LOXO-292, an oral small molecule inhibitor of RET signaling, to improve outcomes in patients with RET fusion–positive non–small cell lung cancer (NSCLC), medullary thyroid cancer (MTC), and other tumors with increased RET activity.

Novel RET Inhibitor Tested in Patients With NSCLC, MTC

Nursing has been rated the most trusted profession for 16 years in a row. Oncology nurses have the special honor of fighting alongside patients and their caregivers at one of the most vulnerable times of their lives. But nurses do not earn professional athlete salaries. So, when and how do nurses get the credit and appreciation they deserve?

For 1 week out of the year, millions of nurses join others to celebrate National Nurses Week, beginning May 6 and ending May 12, Florence Nightingale’s birthday. There are videos, well wishes, cartoons on social media, coupons for free food and drinks, special discounts, and even Nurses Week greeting cards. But 1 week is not enough.

How do we encourage student nurses to explore oncology, inspire new nurses to get a great start in the field, or nurture seasoned oncology nurses to remain in it? This article will explore some ideas for recruitment and retention in the oncology nursing field.

Very few nursing schools offer an oncology elective; many do not have expert oncology faculty. As a result, students are unaware of the endless possibilities in oncology nursing, including hospital staff, clinic, doctor’s office, research nurse, industry, screening and detection, genetic counseling, education, or hospice.

To engage students to consider oncology nursing, the Dallas Chapter of the Oncology Nursing Society (ONS) and many other ONS chapters welcome students at bi-monthly meetings with limited free attendance, and students can attend the Oncology Certified Nurse review meetings for $20. Students are recognized and celebrated each year at the Dallas Chapter’s January anniversary dinner, and scholarships are available from the chapter for its members to get continuing education credit and attend undergraduate and graduate school. The Dallas Chapter’s Board added a student nursing position to better learn about their specific needs. In response to a member survey, the chapter recently organized a social networking time with its first activity at a dine-in movie theater.

Baylor Scott & White Medical Center-Hillcrest in Waco, Texas starts recruiting even before students choose nursing. Each year, staff host a high school senior lock-in for select students with plenty of food, games, special guest speakers, private tours, giveaways, and unique clinical experiences. The teens learn about communication, teamwork, and nurses who fight cancer, as well as get behind-the-scenes tours and a taste of the night shift.

Millennials are the first generation to be conditioned to use technology for everything—they are true digital natives. How does that impact communication and learning and how the profession offers support to nurses of this generation? Millennials often want bite-size communication with more showing than describing. To reach millennials, for example, one might:

 to a continuing education activity or article with a brief introduction. “New article on barriers to participating in clinical trials. Thought it might help you in your new role as research nurse.” No lecture, no lengthy communication, but clear instructions of how it might impact them.

 during orientation to ask, “How is your internship this week?” Although this may seem simple, Millennials prefer more open-ended questions. Listen more, converse.

 of a cartoon with the message, “In case you need a smile today.” Millennials often look for work-life balance, so humor can have a positive impact. They appreciate playfulness, as gaming is ingrained in their lives.

Oncology nursing can be a high-stress environment with significant consequences: turnover, burnout, compassion fatigue, moral distress. Think of ways to promote a positive work environment and celebrate even the little victories. Although some believe a healthy work culture comes from management, it can also grow from the bottom up. Therefore:

Celebrate successes of both individuals and teams.

 Perhaps your patient was able to attend their child’s birthday party because of your suggestions on how to manage fatigue. Or your patient rang the bell today signaling the completion of chemotherapy. Be open to opportunities to celebrate even small accomplishments.

Vow to not complain, criticize, or gossip. Look for ways to compliment or appreciate someone else. Consider writing down 3 good things about each work day.

 Think of ways that you personally or management can sup-port each other that do not break the budget. Create a culture of encouragement and fun. Nurse leader Joni Watson, MBA, MSN, RN, OCN, and her team at Baylor Scott & White celebrated “Something on a Stick Day” and “National Popcorn Day” with cheesy jokes, and the pastoral care department distributed cans of 7-Up soda with a note taped to it reading, “Thanks for going the extra mile! Have a great week. I’ll be UPlifting you in prayer all 7 days this week.”

Look for opportunities to celebrate nurses every day, not just during National Nurses Week. It can make a difference in the way staff feel about their work, themselves, and the profession. What are your tips for celebrating oncology nursing all year long?

Any suggestions to recruit or retain oncology nurses? Share them on Twitter with hashtag 

Professionally Speaking

Consistent recognition can improve morale and help organizations recruit and retain staff.

Celebrating Nurses All Year Long

Hospital volunteers, also referred to as candy stripers, a legacy term that refers to their traditional red-and-white striped uniforms, have been a staple of hospital care, with their influence dating back to the 1940s. Their dedication to helping others while generously donating their time is gracious, selfless, and commendable.

The use of volunteers in hospitals has traditionally been geared toward assisting patients and their visitors. A positive attitude and friendly demeanor is a must, along with effective communication skills. Dedication to helping others, patience, and flexibility are also helpful traits to possess in this area of service.

The benefits to becoming a volunteer vary among healthcare institutions. Some hospitals provide volunteer incentives such as meals, employee discount rates, free health screenings, and skills training. For many, volunteering can be an opportunity to gain work experience, especially for those interested in becoming a healthcare provider.

Volunteering can also provide a sense of service, community, and self-worth. Sarah Lim, a premed student and former pediatric hospital volunteer, says, “I really wanted to give back to my community and gain different perspectives and experiences in settings that I may not have experienced myself. I always had a strong interest to be of service to others. I knew that volunteering would also help me develop other skills that I wouldn’t necessarily learn in the classroom.”

The types of work volunteers will experience may vary greatly. “With a patient-centered role, I was more involved with patients and their families,” said Lim. “It was the complete opposite in the outpatient clinic. I was able to talk to the nurses and get to know them, see their interactions with physicians and the interactions with the patients, learn more about the procedures/treatments done, and get more of a feel of the workplace environment.”

Rady Children’s Hospital-San Diego in California uses volunteers in traditional and innovative roles within their various oncology settings. Danielle Leonard, CCLS, BS, acting volunteer liaison there, explains her role in orienting new volunteers to the outpatient hematology/oncology unit. “I teach new volunteers how to introduce themselves to patients and families, how to maintain appropriate boundaries, the rules surrounding the confidentially of our patients, as well as cleaning and sanitizing policies.” Her volunteers run blood products, clean beds post discharge, transport patients, and restock and obtain needed supplies.

“Volunteers are a vital part of our team,” she adds. “[In the outpatient clinic setting,] they help the nurses immensely and improve overall workflow.”

Mariemel Gawaran, CLA, volunteer liaison, discusses the patient focus of the inpatient oncology unit volunteer role and how special considerations must be taken with a complex patient population. “Some important points that volunteers are taught during orientation is the purpose of the playroom for our patients. Inpatient volunteers welcome parents and let them know they can take a break if they wish. They allow the child real choices in the playroom to allow them some control over their environment. We emphasize the importance of keeping our activity room a safe and therapeutic environment for our patients. Since our patients are immunocompromised, we also emphasize the importance of cleaning and sanitizing toys in between patient use.”

By using volunteers, hospitals are able to maximize efficiency and better serve patients and families. In a busy outpatient setting, such as the hematology/oncology clinic at Rady Children’s Hospital, volunteers help fill gaps by assisting nurses in doing the tasks they may not always have time to do. With many patients coming and going throughout the day on a high acuity unit, getting help from volunteers with certain tasks can make all the difference in allowing for more nursing time at the bedside.

Hospital volunteers are special people. They choose to spend their time serving those who are ill. Even when not assisting patients directly, they contribute largely to overall patient satisfaction by helping healthcare providers, allowing them more hands-on time with patients and their families.

Ashley Hay, BSN, RN is a freelance healthcare writer and owner of AHayWriting.com with more than 10 years of nursing experience in several areas of pediatric and adult oncology.

Fast Facts for the Frontline

Unpaid assistants can help nurses maximize their valuable time with patients.

The Role of Volunteers in an Oncology Setting

Most oncology nurses associate the abbreviation MM with multiple myeloma, but there’s a new MM now in use: medical marijuana. To date, 31 states, the District of Columbia, Guam, and Puerto Rico have approved MM for certain medical uses, including cancer-related adverse events (AEs).

 Patients are asking their oncology nurses if MM might help them and in some cases, after researching the topic themselves, asking very specific questions. Nurses need to be prepared to respond to questions on how MM is supplied and taken, its risks and benefits, and efficacy and safety considerations.

The Cannabis plant, commonly referred to as cannabis and known as marijuana, among other names, produces psychoactive compounds called cannabinoids. Synthetic medications containing cannabinoids, available by prescription, include dronabinol (Marinol) and nabilone (Cesamet). Cannabinoids can be inhaled as smoke or vapor or taken orally (eg, in brownies and other foods).

of using whole-plant cannabis versus synthetic cannabinoid formations. Researchers have explored the use of pharmaceutical cannabinoids, which contain 1 or 2 active ingredients. In contrast, MM often is derived from the entire plant and contains other compounds as well, including the cannabinoids and terpenes (fragrant oils that give cannabis its aroma). Therefore, MM cannot easily be compared with pharmaceutical cannabinoids. Some clinical trials have tested inhaled MM for its antiemetic properties, but not enough data exist for conclusive recommendations.

Potential benefits of MM for adult patients with cancer include appetite stimulation, chronic and neuropathic pain management, improved sleep, and control of chemotherapy-induced nausea and vomiting (CINV). AEs associated with MM include tachycardia, hypotension, muscle relaxation, and decreased gastrointestinal motility. Because cannabinoid receptors are not located in the brainstem areas that control respiration, lethal overdoses from cannabis and cannabinoids do not occur.

Safety considerations include MM use by children and young adults. At this time, the American Academy of Pediatrics has not endorsed pediatric MM use because of concerns about its effect on brain development.

 Plant-derived MM does not have a standardized dose and its optimal dosage is unknown, although the most common advice is to “start low and go slow.”

With inhaled MM, patients “self-titrate,” or adjust the dosage as needed. The goal is to consume the minimum amount needed for symptom relief. Most MM dispensaries also carry edibles that have been tested in independent labs to help ensure safety, and they are labeled with the amount of their ingredients. MM edibles are available as infusions (teas), powders to dissolve in drinks, gummies, mints, chocolate bars, and butter or oils. There are numerous websites that provide guidance on preparing foods containing MM; brownie recipes are among the most popular. MM brownies and other MM edibles should be stored securely in homes in which children and pets reside. In order to qualify for MM, a patient needs to have an approved diagnosed medical condition, which varies by state. After receiving a signed MM recommendation from a licensed physician, the patient applies for an MM card, also known as an MM identification, or cannabis card. This card allows the patient to enter medical dispensaries and purchase MM. The process is simple enough, but do patients really understand MM?

 abounds on the internet, and personal accounts of MM use are limited to individual experiences and are not generalizable to others. People using marijuana recreationally also share their recommendations online. Recreational use of marijuana differs from medicinal use, which can lead to confusion about MM dosing, preparation, and frequency of use. In response to the growing need for clinicians with cannabis expertise, the Society of Cannibas Clinicians was formed, and a US referral directory is maintained on its website.

Patients interested in exploring MM often start by asking their oncologists about it. However, only 30% of 237 US oncologists in a recent survey felt knowledgeable enough about MM to make recommendations (55% practiced in states in which MM wasn’t legalized). Nearly 80% reported discussing MM with patients, and 78% noted these conversations were initiated by patients and their families. The researchers concluded that there is a need for education about MM, as well as clinical trials and further study of MM.

More education is needed for clinicians and patients who may be interested in MM. The National Center for Complementary and Integrative Health maintains a web page containing information for healthcare professionals and con-sumers, some of which is in Spanish.

 The site also includes links to clinical practice guidelines and scientific literature.

Further research is needed because information about MM indications, dosing, drug interactions, and safety considerations is lacking. Comparative studies of MM and other treatments for CINV, anorexia, sleep disruption, and pain management are also needed to further define evidence-based management of these common conditions.

All oncology nurses should have a basic understanding of MM and be prepared to respond to patients’ questions about it. Patients using MM need to be educated to include it in their medication lists when talking with medical providers, especially those patients using edible MM products. Both patients and nurses need to stay abreast of developments in the emerging field of MM and be aware that more research is needed before MM can be considered an evidence-based symptom management approach.

State medical marijuana laws. National Conference of State Legislatures website. ncsl.org/research/health/state-medical-marijuana-laws.aspx. Updated June 27, 2018. Accessed August 1, 2018.

Cannibis and cannabinoids (PDQ)—health professional version. National Cancer Institute website. cancer.gov/about-cancer/treatment/cam/hp/cannabis-pdq#section/_1. Updated June 19, 2018. Accessed August 1, 2018.

MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. 

 2018;49:12-19. doi: 10.1016/j.ejim.2018.01.004.

Society of Cannibas Clinicians website. Cannabisclinicians.org. Accessed August 1, 2018.

Braun IM, Wright A, Peteet J, et al. Medical oncologists’ beliefs, practices, and knowledge regarding marijuana used therapeutically: a nationally representative survey study. 

 2018;36(19):1957-1962. doi: 10.1200/JCO.2017.76.1221.

Medical marijuana. National Center for Complementary and Integrative Health website. nccih.nih.gov/health/marijuana. Updated September 24, 2017. Accessed August 1, 2018.

Nurse's Notes

What to know in responding to patients’ questions about benefits, risks, and access.

The New MM: Medical Marijuana

Kathleen Shannon Dorcy, PhD, RN, FAAN (left)

nurse, Rose Nankinga, in Uganda in January 2018.

From her start washing laundry at a nursing home to her most recent work to improve nurse education in Uganda, Kathleen Shannon Dorcy, PhD, RN, FAAN, has felt she was called to make a difference in world health.

As director of clinical nursing research, education, and practice at the Seattle Cancer Care Alliance (SCCA), and a staff scientist at Fred Hutchinson Cancer Research Center, she mentors many nurses and expands nurse education around the world. She has been a part of moving research to bedside care and believes that nurses make important contributions to improving cancer care.

“The suffering caused by the burden of cancer cannot be underestimated,” she says. “The work we do in nursing, especially oncology, has to be a sense of envisioning better, working as a team to get there.”

This vision has driven Shannon Dorcy throughout her work in clinical care nursing, and she shares that vision with other nurses locally and globally.

After high school, Shannon Dorcy briefly joined a Dominican convent. The Dominicans believe in working with people to search for their personal truths. “The Dominicans believe truth, ‘veritas,’ is always being revealed,” she says.

Within 2 years, Shannon Dorcy left the convent, feeling her search for truth and her calling were better found in education and nursing. As a licensed practical nurse, she worked in a nursing home where she always found a way to connect with the patients through something that was important to them. Soon she was back in school earning a bachelor’s degree in nursing. Afterward, she worked in orthopedics and pediatrics, then pursued her master’s degree in nursing at the University of Washington while working in a research position in pediatric oncology at Fred Hutchinson Cancer Center.

“I had not wanted to be in cancer care,” she says. “I thought it would be too sad.” But her experiences caring for people with cancer changed her mind. “I was captivated by families and children and the people I came in contact with,” she adds.

Shannon Dorcy cared for a 3-year-old girl named Kelly with severe graft-versus-host disease after a bone marrow transplant who had come to Seattle to receive an experi¬mental treatment. Kelly responded well to the treatment, and within a few months, her treatment was approved by the FDA. Kelly was able to go home to Michigan just in time for Christmas and continue to receive the new treatment. “I felt great joy at seeing clinical research move from concept to care and bring a good outcome to a child and her family,” Shannon Dorcy says.

She has continued working at Fred Hutchinson and the SCCA. She has enrolled patients in clinical trials, worked on exciting advances in cancer care, and continued learning. In 2015, she earned her doctorate studying hope and how it influences people to enroll in clinical trials. She has also worked on early research into immunotherapy, targeted therapies, and monoclonal antibodies.

Through decades of experience in clinical research and patient care, Shannon Dorcy has a lot to share with other nurses. She’s committed to improving the profession and supporting nurses in finding their own callings.

“As nurses, we can become weary because of so many pressures,” she says. “How to be a nurse, how to keep up with outstanding scientific development, how to handle the heartbreak as illness takes babies or parents or grandparents. We need to build a sense of connection for ourselves as nurses.”

At SCCA, Shannon Dorcy focuses on empowering nurses to think differently and work with each other as well as other layers of their organizations. She encour¬ages nurses to always ask questions and seek ways to do things better and finds it rewarding to watch the nurses in her organization take the lead. One example is when a protocol was developed to implement a scalp cooling program at SCCA; the nurses were instrumental in bringing that service to patients.

In addition to mentoring nurses, fellows, and students, Shannon Dorcy represents SCCA as part of a community effort called Career Work$ Medical, which prepares participants for careers in the healthcare industry. Seattle is notoriously expensive, and it can be difficult for young people to attend school or get entry-level jobs that will become careers.

“We try to reach young people who are disenfran¬chised and help them find employment across the region,” Shannon says.

Kathleen Shannon Dorcy, PhD, RN, FAAN, (top right corner) with Seattle Cancer Care Alliance colleague Arlyce Coumar, RN, OCN (bottom left), and students in the continuing education course they taught in Uganda.

SCCA’s tagline is “better together,” which extends beyond Seattle to building up cancer care and the nursing field around the world. Shannon Dorcy has also spread her knowledge outside the United States, working with institutions at which SCCA has existing affiliate networks for physicians and researchers to develop stronger programs for nursing outreach. She has taught classes in Guam to help nurses gain oncology certification. Most recently, Shannon and others taught more than 100 nurses at the Uganda Cancer Institute; these nurses stay connected to SCCA and to each other with streaming courses.

“There’s a sense of greatness, not only in the individual, but also in community access,” Shannon says about her work. “The best care happens when everyone comes together.”

Last year, Shannon Dorcy’s lifetime of service to nursing was recognized when she was inducted as a fellow in the American Academy of Nursing. She is excited about the added level of exposure and influence that being a fellow allows her.

“It means I have the power to touch other people across the country, to bring in new ideas and continue scientific exploration,” she says. “I can be part of policy setting and advocate for equitable funding for underresourced areas nationally and globally.”

Feature Story

How Kathleen Shannon Dorcy, PhD, RN, FAAN, became a leading voice in oncology nursing.

Pursuing a Calling: From Convent to Cancer Care

In 2012, when the United States Preventive Services Task Force (USPSTF) released its blanket recommendations against prostate-specific antigen (PSA) testing for prostate cancer, Steve Hentzen was a healthy 46-year old with no known risk factors. PSA screening was discouraged.

 However, his doctor’s insistence on testing saved his life. Hentzen received a diagnosis of advanced prostate cancer. He underwent a radical prostatectomy and later, IMRT radiation treatment. Although his story highlights the importance of PSA-based screening, the test is far from perfect, and the potential for unnecessary harm stemming from inconclusive and misleading results must be considered. Six years later, there are still no simple answers to the question of testing.

After the USPSTF made its recommendations, researchers noted an interesting trend. PSA screening among men age 50 years and older declined significantly, yet approximately 30% of men older than 65 years, with life expectancy estimated at less than 9 years, were still being screened.

 Recognizing the need for a more personalized approach, the USPSTF updated its guidelines in 2018 to include a shared decision-making component for men ages 55 to 69. Although PSA-based screening is effective for discovering cancers of the prostate early on, weighing the benefits against potential harm from overdiagnosis and overtreatment requires an informed discussion between physician and patient before making the decision to test.

Nurses play an important role and are an invaluable resource for patients by keeping them informed and encouraging men to discuss the subject of prostate cancer screening with their physicians. Frank dela Rama, MSN, RN, CNS, AGN-BC, AOCNS, is a prostate cancer nurse navigator at the Palo Alto Medical Foundation, a multispecialty clinic in Silicon Valley. He sees patients newly diagnosed with prostate cancer and helps guide them through the treatment process. Many of the men for whom he helps coordinate care and treatment are “pretty surprised” about their cancer diagnosis, dela Rama says. Often the patients, largely in the 45 to 60 years age group, reported feeling great and were simply following directions by their physicians to get screened.

Since he only sees patients after diagnosis, dela Rama’s perspective on PSA-based screening is colored by the benefit of early detection. He is well-versed about the adverse events of treatment and helps educate patients about various options available, such as MRI-guided biopsies for high-risk patients to aid visualization of the tumor. “Sometimes active surveillance is the best treatment,” he says.

Hentzen is now the chairman and a cofounder of ProstateNetwork.org, a survivor-led nonprofit outreach and advocacy group for men diagnosed with prostate cancer. He is a strong proponent for routine screening and his argument is both personal and compelling.

Those who support recommendations against routine screening, however, have their own passionate reasoning for doing so. Prostate cancers are often slow-growing and asymptomatic, whereas harms associated with overdiagnosis and overtreatment, including infection, pain, bleeding, erectile dysfunction, and urinary complications, can be physically and psychologically traumatic. After analysis of two major studies and other reports on PSA screening, the National Cancer Institute (NCI) estimated that “for every 1000 men ages 55 to 69 years who are screened every 1 to 4 years for 10 to 15 years, about 1 death from prostate cancer would be avoided.”

False-positive results are not uncommon, and treatment for confirmed disease that might not have otherwise been problematic, can negatively affect quality of life.

For many physicians, engaging patients in a shared decision-making process can be a time-consuming and often uncomfortable endeavor. Fear of litigation, reluctance to discuss life expectancy issues, lack of knowledge, and time constraints are some of the reasons identified in a 2014 study as to why men were screened against recommendations.

 Addressing practice issues and providing professional education can help ensure that physi¬cians have the tools and resources needed to best serve their patients.

Efforts to improve the quality and specificity of PSA-based screening is ongoing, but more research is needed before the usefulness of newer tests such as PSA-velocity, -density, and free versus total PSA, is realized. Healthcare providers should have a solid understanding of implications for their patients by reviewing available information and staying informed about advances in research and applicability to practice. It is important to note that in addition to the widely publicized USPSTF recommendations, other, more comprehensive guidelines are available from organizations including the National Comprehensive Cancer Network and the American Cancer Society.

Effective shared decision-making keeps the patient’s best interest front and center. Although prostate cancer is the leading non—skin cancer and the second leading cause of cancer death in men, patients do not know what they need to. Fortunately, many resources are available to help educate men throughout the process, including important questions to ask along the way, details about treatment options, and where to go for help and support.

Prostate nurse navigators like dela Rama are often called on by primary care physicians, urologists, and nurse clinicians for resources and direction. They also offer community outreach services to better educate men about prostate cancer. “Sometimes patients may ask for an unnecessary test or treatment not covered by insurance,” dela Rama said, “and urologists express uncertainty about the usefulness of some tests.” Their expertise at navigating the complexity of treatment is beneficial to patients.

The good relationships nurses have with their patients enable them to provide exceptional care, dela Rama points out. “[Men] love to be independent. They want to ‘warrior through’ everything. Nurses can educate them on the pros and cons of testing, the importance of talking to their doctor, test interpretation, and timing of the tests.”

When it comes to baseline screening, for example, scheduling the PSA before the digital rectal exam is conducted helps yield more accurate test results. Advising patients to refrain from ejaculation and any physical activity that puts prolonged pressure on the prostate (eg, long bicycle or motorcycle riding) 3 days before having PSA levels drawn is also important for a more precise reading. In dela Rama’s opinion, “nurses educate better than anyone on the planet,” which is why staying abreast of current trends and treatments is vital.

As for the role of genomics in prostate cancer management, dela Rama explained that genomic testing is currently integrated into the process—after diagnosis and before treatment. By using genomic testing, some of which is covered by insurance, physicians can learn how “angry” or aggressive tissue samples are. This information can help guide decisions about active surveillance versus treatment, as well as determine the course and timing of treatment. The possibilities of genomics are just beginning to be realized. Additional research and increased funding for high-quality studies is needed to move prostate cancer care to a higher level of precision.

Steve Shak, MD, is co-founder, chief scientific officer, and chief medical officer of Genomic Health, the world’s leading provider of genomic-based diagnostic tests. In an interview with 

, he talked about genomic testing and how it can prevent overtreatment and address underdiagnosis. “We started the company with the dream to move away from the one-size-fits-all [approach]. Genomics helps us address illness in a more targeted way.”

Shak thinks of genomics as precision medicine. One of the tests developed by his company, the Oncotype DX Genomic Prostate Score (GPS), uses a small amount of material taken from an initial biopsy. “A complex series of procedures are then completed to quantify a set of 17 genes that tell us whether a prostate cancer is aggressive or not,” Shak explained. “While PSA testing may reveal a rising or high level, it is impossible to know without tissue whether there is a benign cause.” In this regard, genomic testing addresses the gap the USPSTF used as a basis for its recommendations. “The task force had reasons to be concerned,” he says. “If everyone gets a biopsy showing a little bit of cancer, it might lead to radical treatment and unnecessary procedures. It is not enough to do things right, we also need to do things smart.”

The promise of genomics is encouraging. Shak credits the growth in this area to the collaborative efforts of leading clinical researchers, patient advocates, the NCI, and other cancer organizations. Nurses also played a pivotal role as patient advocates and in helping men with prostate cancer enroll in appropriate studies. “That is how advances are made,” Shak says.

The goal is to get the right treatment to the right patient at the right time. “We have innovations; when we spare patients from unnecessary treatment, we also save the healthcare systems’ dollars that could be spent better on other things. Cost effectiveness matters.”

The Oncotype DX GPS is covered by Medicare and multiple private insurance companies, and other genomic tests are available on the market, each with specialized purposes, some of which may also be reimbursable by insurance or Medicare coverage.

For now, the question of conducting PSA-based screening for prostate cancer is best answered through informed decision-making between a man and his physician. “Doctors need to cover everything,” Hentzen stresses. “We should not expect men to have knowledge about this complicated subject.” Hentzen is doing his part to help lower the rates of advanced diagnoses through targeted outreach and education.

PSA tests are not definitive and not all biopsies are created equal. Men, in conversation with their doctors, should decide what to do if screening results come back elevated before testing is conducted. Informed decision-making calls for more than a quick visit, and physicians must be prepared to discuss difficult topics such as life expectancy and untoward effects of treatment openly with their patients. Nurses can help by educating men and encour¬aging them to ask questions.

As the debate over prostate cancer screening continues, and the promise of genomics offers options for reducing harm, perhaps it is time to ask: Are we giving patients the best care we can offer? Every patient? If not, now is the time to start.

Ellen Rice Tichich, MFA, MSN, RN-BC is a clinical nurse educator and freelance health writer.

Drazer M, Huo D, Eggener SE. National prostate cancer screening rates after the 2012 US Preventive Services Task Force recommendation discouraging prostate-specific antigen-based screening. 

2014;33(22):2416-2423. doi: 10.1200/JCO.2015.61.6532.

Drazer M, Prasad S, Huo D, et al. National trends in prostate cancer screening among older American men with limited 9-year life expectancies. 

Final recommendation statement: prostate cancer: screening

U.S. Preventive Services Task Force website. uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening1. Published May 2018. Accessed June 15, 2018.

Prostate-specific antigen (PSA) test. National Cancer Institute website. cancer.gov/types/prostate/psa-fact-sheet. Reviewed October 4, 2017. Accessed June 15, 2018.

Cover Story

There are still no simple answers to the question of screening for prostate cancer.

To Test or Not to Test? Pros, Cons, and the Promise of Genomics in Prostate Cancer

Although JAK inhibitors are a proven effective treatment for patients with myelofibrosis, a type of myeloproliferative neoplasm (MPN), they may come with a severe downside; in particular, a 16-fold increase in the chance of developing a B-cell lymphoma, according to recent research published in the journal 

Researchers examined 626 patients with MPNs who were diagnosed and treated at the Medical University of Vienna between 1997 and 2016. Of these patients, 69 with myelofibrosis were treated with a JAK1/2 inhib&shy;itor for lymphoma development, which included ruxolitinib (Jakafi), gandotinib, fedratinib, or momelotinib.

Four of these patients (5.8%) developed a B-cell lymphoma compared with 2 patients (less than 1%) who were not treated with a JAK inhibitor.

In a similar assessment of 929 patients with MPNs, including 216 mye-lofibrosis cases, 3 (9.7%) of 31 patients treated with JAK1/2 inhibition developed a lymphoma compared with 1 patient (0.54%) in the control group.

The lymphomas that arose in the study included diffuse large B-cell lymphoma (DLBCL) and high-grade B-cell lymphoma not other-wise specified.

Incyte, the manufacturer of ruxolitinib, offered a statement that in a large study, they found no correlation at all between their drug and aggres&shy;sive lymphoma.

“An extensive review of the ruxolitinib global safety database, which includes nearly 80,000 patient-years, does not reveal an association between ruxolitinib therapy and lymphomas. We are continuing to evaluate the analysis, but would note that the analysis was not adequately controlled and did not account for factors such as prior treatment exposure, time since MPN diagnosis, or the point at which the JAK1/2 inhibitors were initiated in the patients’ disease course.”

To better understand the potential correlation between JAK inhibition and lymphoma, study author Ulrich Jager, MD, head of the Division of Hematology and Haemostaseology at the Medical University of Vienna in Austria, said that prospective evaluation of these data in larger clinical trials is needed. He also suggested that his colleagues in the hematology/ oncology space report when their patients who are treated with JAK inhib&shy;itor therapy go on to develop lymphoma.

Adverse Events Report

Although JAK inhibitors are a proven effective treatment for patients with myelofibrosis, a type of myeloproliferative neoplasm (MPN), they may come with a severe downside; in particular, a 16-fold increase in the chance of developing a B-cell lymphoma, according to recent research published in the journal Blood.

September 2018