Clinical Insights: April 2018


CE lesson worth 1 contact hour that is intended to advanced practice nurses, registered nurses, and other healthcare professionals who care for patients with cancer.

Release Date: April 22, 2018Expiration Date: April 22, 2019

This activity is provided free of charge.


This CE article is designed to serve as an update on cancer detection and prevention and to facilitate clinical awareness of current and new research regarding state-of-the-art care for those with or at risk for cancer.


Advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients may participate in this CE activity.


Upon completion, participants should be able to:

  • Describe new preventive options and treatments for patients with cancer
  • Identify options for individualizing the treatment for patients with cancer
  • Assess new evidence to facilitate survivorship and supportive care for patients with cancer


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This CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CE activity is for continuing medical nursing purposes only and is not meant to substitute for the independent medical judgment of a nurse or other healthcare provider relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual authors and do not reflect those of PER®.


New Tool Generates Effective Survivorship Care Plans

Katie Kosko

Tailored care plans may offer head and neck cancer survivors more information focused on care after treatment to address late-term adverse effects, according to findings presented at the 2018 Cancer Survivorship Symposium.

Investigators from Hartford Hospital in Connecticut and Memorial Sloan Kettering (MSK) Cancer Center in New York, New York, were interested in determining the acceptability and usefulness of survivorship care plans (SCPs) for patients with head and neck cancer.

“Head and neck cancer survivors can be symptomatic, with a lot of [concerns] that affect their eating, speaking, breathing, body image, and other issues,” senior author Talya Salz, PhD, an assistant attending outcomes research scientist at MSK, said in an interview with Oncology Nursing News®. “Even these symptomatic patients—mainly who are elderly—are willing to use a computer interface to report their symptoms before a routine survivorship visit.”

The investigators developed a tool that not only helped assess these factors but also generated SCPs, which consist of documents that summarize a person’s cancer diagnosis and treatment and outline an ongoing plan of care for survivors. The platform, called the Head and Neck Survivorship Tool: Assessments and Recommendations (HN-STAR), was designed based on guidelines issued by the American Cancer Society and endorsed by the American Society of Clinical Oncology.

Survivors entered adverse effects into a computer—either in the waiting room or at home—and a nurse separately entered treatment details. Survivors reported on 22 late-term adverse effects (AEs) prior to routine clinic visits. The most common were dry mouth (70%), neck or shoulder stiffness (65%), fatigue (65%), and insomnia (56%). Based on the information entered, HN-STAR created an SCP with a treatment summary, wellness recommendations, and management of adverse effects. A nurse could then discuss the best plan of action with the survivor.

The surveys were completed by 47 survivors, made up mostly of white men who had an oropharynx tumor. The majority (81%) had received multimodality therapy, and 51% had experienced at least 9 of the 22 late-term adverse effects in the month leading up to the survey.

Ninety-one percent of survivors found the SCP easy to follow, and nearly all (98%) said they both intended to follow the recommendations for managing AEs and would refer to the SCP. The survey also revealed that head and neck cancer survivors (87%) planned to share their SCPs with their primary care providers.

“The idea is that this can help the survivor know who to visit next and help with self-management,” Salz said, “And we saw that they viewed the document very favorably.” Surveyed primary care providers also were in favor of tailored SCPs. The investigators determined that 95% were satisfied with the SCP, and the same number said they wanted to have one for every patient with cancer.

“We asked, ‘How comfortable are you preventing, diagnosing, or managing these complicated late effects?’ and there was a wide variety in their comfort,” Salz said. “It seems like there is room to help primary care providers learn how best to help these complex cancer survivors, and that this plan might be able to help them.”

The investigators hope to get funding for a multicenter trial to see how well this can be implemented in more clinics. “This study is one of the first steps in ‘Does this work?’” Salz said. “Survivors want more information. There is poor coordination of care for survivors, and we need to help people move from an acute treatment focused care to survivor focused care.”

Colorectal Cancer

Older Patients With Colorectal Cancer Are More Likely to Develop Cardiovascular Disease

Jason Harris

Older adults with colorectal cancer (CRC) are at increased risk of new-onset cardiotoxicity, according to results from an analysis of the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute. Investigators reported that in these patients, both diabetes and hypertension interact with chemotherapy to increase the risk of cardiovascular disease (CVD) and congestive heart failure (CHF).

The median age at diagnosis was 78 years (range, 66-106), with a median follow-up of 8 years since diagnosis. At 10 years, the cumulative incidence of new-onset CVD was 57.4% in the study population, and the cumulative incidence of new-onset CHF was 54.5%. Those rates were 22% and 18%, respectively, in the age-matched control group (P <.001).

Time to CHF diagnosis was 58% shorter in patients with CRC compared with noncancer controls (HR, 4.19; 95% CI, 14.06-4.33). Time to developing CVD was 57.4% shorter in CRC patients, which translates to a 3.07-fold increased risk of CVD (95% CI, 2.98-3.16).

“Older survivors of colorectal cancer carry a substantial burden of cardiovascular morbidity,” first author Kelly M. Kenzik, PhD, of the Institute for Cancer Outcomes and Survivorship, Division of Hematology and Oncology, at the University of Alabama at Birmingham, and colleagues wrote.

“Risk of morbidity increases with age and is influenced by exposure to FU [fluorouracil] and capecitabine and preexisting comorbidities. These findings provide evidence for close medical surveillance and the potential need for aggressive management of preexisting comorbidities of those with colorectal cancer who are at increased risk of cardiovascular morbidity,” added Kenzik et al.

The research team analyzed data on Medicare- enrolled adults older than 65 years diagnosed with incident stage I to III colon or rectal cancer diagnosed from January 1, 2000, to December 31, 2011. Medicare claims were captured until death or December 31, 2013. Cumulative incidence functions, censoring for death, were used to assess the risk of new-onset CHF and CVD separately, as well as the risk of cardiovascular morbidity.

Women made up 55% of the study population, and 86% of the study population was white. Half of patients had been diagnosed with stage III colorectal cancer. Investigators randomly selected a 5% noncancer sample of Medicare beneficiaries who resided in SEER catchment areas to serve as the control group.

The findings revealed a significant interaction between hypertension and chemotherapy for CVD (P <.001) and between diabetes and chemotherapy for CHF (P <.001). The use of capecitabine appeared to have a significant effect on cardiotoxicity risk. At less than 2 years since diagnosis, patients who received capecitabine alone had a 3.65-fold increased risk of CHF (95% CI, 2.76-4.38) compared with those who received fluorouracil monotherapy. At 2 or more years since diagnosis, patients who received capecitabine alone had a 1.57-fold increased risk of CHF compared with those who received fluorouracil alone.

However, patients who received capecitabine alone had a lower risk of CVD compared with patients who received fluorouracil alone (HR, 0.63; 95% CI, 0.53-0.75) less than 2 years since diagnosis. Patients who received capecitabine alone also were at a lower risk 2 or more years since diagnosis (HR, 0.72; 95% CI, 0.62-0.84). African American race/ethnicity (HR, 1.22; 95% CI, 1.15-1.29; P <.001) and radiation therapy (HR, 1.30; 95% CI, 1.22-1.37; P <.001) were associated with significantly accelerated time to CHF. Preexisting comorbidities, except hypertension, dyslipidemia, and liver disease, also independently accelerated the time to CHF.

Factors that significantly accelerated the time to CVD included African American race/ethnicity (HR, 1.17; 95% CI, 1.11-1.25; P <.001) and radiation therapy (HR, 1.18; 95% CI, 1.11-1.25; P <.001). All preexisting comorbidities, with the exception of liver disease, significantly accelerated time to CVD.


Kenzik KM, Balentine C, Richman J, Kilgore M, Bhatia S, Williams GR. New-onset cardiovascular morbidity in older adults with stage I to III colorectal cancer [published online January 16, 2018]. J Clin Oncol. doi: 1200/JCO.2017.74.97.

Nurse Perspective

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

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

Laura Metcalfe, MSN, RN, APN-C, AOCNSJohn Theurer Cancer Center, Hackensack, NJ

The American Cancer Society reports that the median age at which colon cancer is diagnosed is 71, and patients aged 75 years and older with stage III colon cancer account for 40% of the colorectal cancer population in the United States. In a 2012 study, Sanoff HK et al found that this group of patients may expect a survival benefit from adjuvant chemotherapy that rivals that previously reported in younger patients.

In our practice, we certainly have many patients in their 80s and even some in their 90s who have received adjuvant chemotherapy without apparent ill effect. Of course, all patients, independent of age, are assessed for their ability to undergo chemotherapy. Performance status and comorbidities are taken into account, and chemotherapy regimens, as well as doses, are adjusted accordingly.

Given that, according to the American Heart Association nearly 46% of Americans have hypertension and reports that about 25% over the age of 65 have diabetes, many of our patients have at least 1 if not both of these cardiovascular risk factors. Unfortunately, exposure to either fluorouracil or capecitabine increases the risk; however, these are the standard chemotherapy drugs given for colorectal cancer. So what do we do?

I do not believe this warrants not offering chemotherapy to elderly patients, because we know it can benefit them by preventing risk of recurrence and thereby extending life. However, knowledge is power. Including cardiovascular disease in the discussion regarding risks and benefits of adjuvant chemotherapy gives the patient the ability to make an informed decision.

For each patient, the decision about whether or not to have chemotherapy is a balance between the potential benefits and adverse effects. Further, encouraging patients who have either uncontrolled hypertension or diabetes to seek appropriate medical care and maintain better control could help decrease their risk.

At the completion of adjuvant therapy, we provide all our patients with a survivorship care plan with recommendations for lifestyle changes that can decrease their risk of recurrence, as well as recommendations for routine medical follow-up and cancer surveillance. For patients aged 75 years and older, especially those with hypertension and/or diabetes, cardiovascular surveillance should be included in their care plans.

Ovarian Cancer

USPSTF Recommends Against Ovarian Cancer Screening in Average- to Low-Risk Women

Kristie L. Kahl

Women with no known high-risk hereditary syndrome should not be screened for ovarian cancer, according to the US Preventive Services Task Force (USPSTF). The USPSTF reviewed evidence from 3 “good-quality” studies on the benefits and harms of ovarian cancer screening in asymptomatic women with no known high risk of the disease. In particular, investigators on the task force evaluated ovarian cancer mortality, quality of life, false-positive rates, surgery and surgical complication rates, and psychological effects from screening.

The task force found adequate evidence that screening with transvaginal ultrasound or testing for the serum tumor marker cancer antigen-125 (CA-125)—or both&mdash;does not reduce ovarian cancer mortality. In addition, they found that most women had false-positive results after screening, which led to unnecessary surgical interventions in a group of women who did not have cancer.

Ultimately, in a reiteration of its 2012 recommendation, they concluded with “at least moderate certainty” that the harms of screening outweighed the benefits. “Given the lack of mortality benefit of screening, and the moderate to substantial harms that could result from false-positive screening test results and subsequent surgery, the USPSTF concludes with moderate certainty that the harms of screening for ovarian cancer outweigh the benefit, and the net balance of the benefit and harms of screening is negative,” the task force wrote.


The largest and most recent trial, the randomized UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), included 202,638 postmenopausal women aged 50 to 74 years, not known to be at high risk of ovarian cancer, who underwent CA-125 screening or transvaginal ultrasound. After a median follow-up of 11.1 years, ovarian cancer mortality was not significantly different among both screening groups, as well as compared with a control group who received no screening. In addition, there was no significant difference in mortality risk in the transvaginal ultrasound (HR, 0.91; 95% CI, 0.76-1.09) compared with the CA-125 (HR, 0.89; 95% CI, 0.74-1.08) groups.

The UKCTOCS pilot trial included 21,955 women to evaluate the use of a single cutoff value for CA-125 testing. Again, the investigators found no difference in ovarian cancer mortality.

In the US-based Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, 68,557 women were randomized to receive either annual screening—using both CA-125 and transvaginal ultrasound&mdash;or usual care. After a median follow-up of 12.4 years, the investigators found no difference in ovarian cancer mortality among groups. Recent analyses of the trial, which added 6 more years of data, also did not find evidence to support long-term benefits from screening.

Based on all 3 studies, the false-positive rates were 11.9% among women screened with transvaginal ultrasound and 9% in those screened with CA-125.

A fourth study, the Quality of Life, Education and Screening Trial (QUEST), determined quality of life and the psychological harms of screening among 549 women. Although investigators found no statistically significant difference in cancer worry between screening groups, women with abnormal test results were more likely to report cancer worry at 2 years of follow-up (odds ratio, 2.8; 95% CI, 1.1-7.2) than women who did not have abnormal results.

“This recommendation statement is consistent with the 2012 USPSTF recommendation,” the task force wrote. “Since 2012, the large UKCTOCS trial was published, and, much like the PLCO trial, it did not find that screening for ovarian cancer reduces ovarian cancer mortality in asymptomatic women not known to be at high risk for ovarian cancer.”


In conjunction with the USPSTF’s recommendation, Karen H. Lu, MD, added that early detection strategies are possible. “Important lessons learned over the last 2 decades should help to develop improved strategies for early detection of ovarian cancer,” she wrote in an accompanying editorial.

In her editorial, Lu suggests that a 2-stage strategy, including a first-stage, inexpensive test followed by an imaging test, could be effective in early detection. She also highlights the fact that samples used for the discovery of new biomarkers must be “prediagnostic.” Finally, Lu acknowledges that validation of candidate biomarkers is essential, and previous studies, such as UKCTOCS and PLCO, could serve as validation of these new candidates.

“While efforts continue to identify effective strategies for early detection, to truly reduce the morbidity and mortality of ovarian cancer, a complementary prevention strategy also will be needed,” according to Lu. “Broadening the strategy to include accurate risk models and genetic testing, novel prevention options, and effective early detection may help reduce the incidence and high mortality associated with ovarian cancer.”

Nurse Perspective

 Marieta Branis, DNP, ANP, NP-C

Marieta Branis, DNP, ANP, NP-C

Marieta Branis, DNP, ANP, NP-CWomen’s Oncology Division, John TheurerCancer Center, Hackensack,

The majority of ovarian cancers are diagnosed as advanced stage disease, which leads to poor prognosis and unfavorable patient outcomes. The purpose of screening for ovarian cancer is to identify women who may present with treatable, early stage disease. The 2 most common methods used to screen for ovarian cancer are a blood test known as CA-125 and transvaginal ultrasound. Research has shown that the predictive benefit of screening every woman for ovarian cancer has been limited and, therefore, not recommended.

The high rate of false positive results reported by the screening methods has been linked to emotional distress and unnecessary testing, without any change in the reported mortality rate associated with the disease. In the absence of family history of ovarian cancer and/or BRCA1 and BRCA2 genetic mutations, or presentation of specific symptoms such as abdominal ascites, abdominal pain, and urinary or bowel symptoms, screening for ovarian cancer has been shown to be of little value in detecting ovarian cancer at an early stage.

The recent review conducted by the USPSTF concluded that screening for ovarian cancer in average low-risk women is not recommended. Average low-risk women were identified as postmenopausal women between the ages of 50 and 74 years, with no known risk of ovarian cancer. Although all women are at risk of developing ovarian cancer during their lifetime, the current evidence shows that screening for ovarian cancer does not decrease the mortality risk associated with this disease; therefore, screening should be performed just on those women who are considered high risk.

Breast Cancer

Women Who Undergo Lymph Node Dissection Regain Arm Mobility Faster With Exercise

Kristie L. Kahl

In addition to educating on adverse effects, nurses should communicate the benefits of physical therapy to women with breast cancer who underwent lymph node dissection, so they can regain arm mobility sooner.

Study findings presented at the 2018 Cancer Survivorship Symposium showed that physical therapy intervention not only helped but also enabled women to regain full range of motion much sooner than without it. Lymph node dissection, the surgical removal of 1 or more groups of lymph nodes, results in a 2- to 3-inch incision in the skin crease of a patient’s arm. Lymphedema, or swelling, can occur. “Lymph node dissection, whether it is axillary or sentinel, often results in restrictions of arm movement, including range of motion. These restrictions…can be temporary or permanent,” Electra D. Paskett, PhD, MO, the Marion N. Rowley Professor of Cancer Research and director of the Division of Cancer Prevention and Control at The Ohio State University in Columbus, said during a press cast. Paskett and colleagues conducted a secondary analysis of the Lymphedema Education and Prevention (LEAP) study, a randomized controlled trial designed to determine if a lymphedema prevention program could help patients to regain range of motion in both the affected arm and unaffected arms.

At 41 participating sites, women were randomized to receive either education only or education plus exercise. The 253 women who received education only were given information about lymphedema signs and symptoms, as well as risk reduction strategies. The 315 women who received education plus exercise were given the same information, as well as arm stretching and breathing exercises and a visit with a physical therapist.

“The physical therapist discussed lymph flow, strengthening, and breathing exercises [and] fitted women with an elastic compression sleeve and gauntlet and told them when to wear it,” Paskett explained. “Women were given 2-pound hand weights, and then they were given a take-home video that demonstrated all of the exercises that they were taught in this session.”

The patients answered self-administered surveys to determine how well they could reach with each arm before surgery and again at 12 and 18 months after surgery. Range of motion was reported as very little, about half, nearly full, overhead, and full.

Before surgery, women in the exercise group were less likely to report full range of motion for both arms compared with the education-only group— just 58% compared with 75% in the left arm and 57% compared with 76% in the right arm, respectively.

At 12 months after surgery, women in the exercise group reported greater range of motion compared with those in the education-only group, with an improvement of 91% compared with 84% in the left arm and 90% compared with 83% in the right arm, respectively. By 18 months, 93% of women in both groups reported full range of motion in both arms.

The investigators used a fully adjusted model, which looked at the arm specifically affected by surgery, and included baseline weight, type of surgery, lymph node dissection, whether that arm was dominant, and whether the patient received radiation therapy and/or chemotherapy. In this model, women who received both education and exercise experienced a 32% increase from before surgery to 12 months after, compared with just 6% of women who received only education on lymphedema. At 18 months, range of motion increased even more, to 37% and 13%, respectively.

“Our take-home message here is that all women receiving lymph node dissection, whether it is axillary or sentinel, should receive physical therapy to regain range of motion more quickly after surgery and, thus, help maintain physical functioning,” Paskett said.

Timothy Gilligan, MD, MSc, FASCO, an American Society of Clinical Oncology expert in survivorship care and a medical oncologist at Cleveland Clinic Taussig Cancer Institute in Ohio, acknowledged the importance of these results. “This…is a big quality of life issue for women who have lymph node dissection for breast cancer,” said Gilligan, who moderated the press cast. “The good news here is that physical therapy can help. Women should be aware of this and have access to physical therapy so they can benefit from this.”

Endometrial Cancer

Geography, Race, and Genetic Variation in Endometrial Cancer

Jason Harris

Investigators at University Hospital State University of New York (SUNY) Downstate recently found that black women of Caribbean descent with type I or II endometrial cancer expressed significant differences in genetic variations compared with a nationwide population of patients with endometrial cancer.

Albert Palileo, MD, a third-year gynecologic oncology fellow with the hospital, presented these findings at the 2018 Society of Gynecologic Oncology Winter Meeting. In an interview with Oncology Live®, a sister publication of Oncology Nursing News®, Palileo noted that although these results are not robust enough to guide treatment decisions, they may contribute to a more personalized treatment approach. “There does seem to be some molecular basis—some genetic basis&mdash; for why we see a difference in how our patients respond to treatment, how they present, and what cancers they ultimately end up getting,” he said. “So, we’re hoping this adds to the pool of molecular profiling data and, ideally, will contribute in the future to targeted therapies and advanced prognostic factors.”

SUNY Downstate is located in a Brooklyn, New York, neighborhood with a high black Caribbean population; Palileo estimated that more than 90% of patients treated there fit that demographic. This group is not often included in clinical trials, so physicians set out to evaluate what they had seen in practice. “We’ve noticed anecdotally that they have different presentations in their cancers and different prognoses,” he said. “They tend to present a bit more at a progressed level, but we wanted to put a number to it.”

Between 2015 and 2018, investigators collected 55 tissue samples with full profiling, including 24 type I samples and 31 type II, which were analyzed using immunohistochemistry and next-generation sequencing of 165 genes at Caris Life Sciences. The results were compared with 3133 endometrial cancer samples from a nationwide population collected by Caris.

“For the most common mutations we saw in our type I patients, PTEN was the most common at 56%, followed by BRCA2, PIK3CA, and some others like CTNNB1. In terms of our type II cancers, as expected, we saw p53, some mutations in FBXW7, and also PIK3,” Palileo said. “Interestingly, when we compared [our data] to the national population, we found some clear differences. For example, in type II cancers, in nationwide data, BRCA mutations were about 17%, whereas in our population, we had no patients with BRCA mutations.”

Expression of BRCA1 (13.6% vs 8.3%; P = .365), BRCA2 (45.5% vs 38.9%; P = .033), and ATM (8.7% vs 3.6%; P = .198) was higher among Caribbean patients with type I disease compared with the nationwide population. However, the opposite was true among pa-tients with type II disease for BRCA1 (0% vs 10.8%; P = .053) and BRCA2 (0% vs 17.2%; P = .011). Expression of ATM remained higher among type II Caribbean patients versus the nationwide group (6.7% vs 2.2%; P = .12). APC expression was lower among the Caribbean patients in the type I (17.4% vs 21.1%; P = .028) and type II groups (13.3% vs 2.9%; P = .001).

Expression of c-KIT was low for type II patients in both groups (Caribbean, 0%; nationwide, 0.5%; P = .696). Among type I patients, 8.7% of Caribbean patients were positive for c-KIT compared with 1.2% nationwide (P = .001).

Type I patients in the nationwide population were much more likely to be positive for TP53 (4.3% vs 23.7%; P = .03). TP53 expression was nearly identical in type II patients (67% vs 66.7%; P = .797).


Testani E, Chen M, Lee R, et al. Molecular profiling of endometrial carcinomas in a Caribbean black population. Poster presented at: Society of Gynecologic Oncology 2018 Annual Winter Meeting; February 8-10, 2018; Aspen, CO.

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