Clinical Insights: December 2020


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: December 22, 2020Expiration Date: December 22, 2021

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


Physicians’ Education Resource®, LLC is approved by the California Board of Registered Nursing, Provider #16669 for 1 Contact Hour.


It is the policy of Physicians’ Education Resource®, LLC (PER®) to ensure the fair balance, independence, objectivity, and scientific objectivity in all of our CE activities. Everyone who is in a position to control the content of an educational activity is required to disclose all relevant financial relationships with any commercial interest as part of the activity planning process. PER® has implemented mechanisms to identify and resolve all conflicts of interest prior to release of this activity.The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial interests pertaining to this activity.


  • Read the articles in this section in its entirety.
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  • Print your CE Certificate.


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®.

C. Diff

Preventing the Spread of Clostridioides Difficile in Oncology Units

By Brielle Benyon

Hospital-acquired infections can negatively affect outcomes in patients with cancer, so it is imperative that oncology nurses are vigilant about preventing them. After seeing a spike in Clostridioides difficile (C diff) infections a few years ago, nurse investigators at City of Hope National Medical Center in Duarte, California, conducted a root cause analysis and then created an intervention plan to stop the spread.

The results were presented by Karen Wohlgezogen, BSN, RN, CPHON, assistant clinical nurse manager at City of Hope, during the 2020 Oncology Nursing Society Bridge virtual conference, held September 8 to 17, 2020.1

“C diff is a spore-forming [bacterium] that is very resilient and difficult to kill,” Wohlgezogen said. “It causes life-threatening diarrhea and colitis.”

In their initial analysis, the investigators realized that C diff infections were occurring in adjacent rooms during the same time frame, which suggested a role of staff in spreading the infection, Wohlgezogen explained, also noting that some staff members were unable to correctly answer questions about how to adequately clean shared equipment. They also noticed family members of patients in isolation rooms not washing their hands when they left the room.

“Any time you’re cleaning anything having to do with C diff, you definitely have to use bleach so it’ll kill the spores. Alcohol gel and alcohol wipes don’t do it,” Wohlgezogen said. “But we had complaints from staff, patients, and families about using bleach. They didn’t like the strong smell, [and] it seemed to stain the clothes of the staff using it.”

Addressing the issue began with patient and staff education. In addition, nurses were put in charge of providing patients and families with any items they wanted or needed, such as coffee or snacks, and they were tasked with making sure that objects were cleaned appropriately before and after use.

Next, they realized the importance of patients bathing or showering daily to decrease the bacterial count on the body. Then, the team determined that bedside commodes likely were not being cleaned as thoroughly as they should be, particularly the heavy-duty bucket component that catches the waste. Therefore, City of Hope began to invest in single-use patient items.

“Once we [changed] the bedside commode buckets [to] single use, we definitely saw a decrease [in C diff],” Wohlgezogen said.

The team also ensured that there were enough vital sign monitors that one could be kept in the room of each oncology patient in isolation for the duration of their stay without needing to be shared with other patients. Similarly, they encouraged limiting movement of computer workstations on wheels among isolation patients’ rooms when possible.

“Our recommendation is to maintain a high focus on [C diff] infection prevention and [to continue] the education with the nursing [and medical] staff, patients’ families, and all the people who touch the patients,” Wohlgezogen said.


1. Wohlgezogen K. Decreasing C. difficile infection rates: the bundle approach. Presented at: 2020 Oncology Nursing Society Bridge virtual conference; September 8-17, 2020; Virtual. Accessed September 22, 2020.


Opioid Overview: Know What to Use and When

By Brielle Benyon

Patients with cancer can experience immense pain, and it is crucial that oncology nurses know how to effectively—and safely—manage that pain.

“Pain management is both an art and a science. You really have to see how the patient is doing. How are they tolerating the opioids?” said Jeannine Brant, PhD, APRN, AOCN, FAAN, an oncology clinical nurse specialist and the director and lead scientist of Collaborative Science and Innovation at Billings Clinic in Montana. Brant recently led a presentation on opioid use at the 2020 Oncology Nursing Society Bridge virtual conference, held September 8 to 17, 2020.1


Brant said that morphine is “the gold standard for comparison for all opioids” because it is inexpensive and can be given orally or rectally, in immediate- or controlled-release form, and can even be injected into the space or fluid around the spinal cord.

Morphine has 2 metabolites (byproducts of the body breaking down the drug): morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). Nurses should be aware that for patients with compromised kidney function, M3G and M6G accumulate in the body and can cause adverse events (AEs) such as neurotoxicity, nightmares, hallucinations, or oversedation.

This opioid is not completely off the table for patients with renal insufficiency, but clinicians should adjust the dose appropriately.


Oxycodone, which is primarily administered orally and is sometimes combined with acetaminophen, is another common and versatile opioid option for patients with cancer.

Frequently, patients who experience AEs from morphine will switch to oxycodone. However, clinicians should be cautious when combining oxycodone and acetaminophen.

“We have to be careful of [combining the drugs] because we should limit acetaminophen to even less than 4 [grams] a day. Oftentimes, the limits are lower,” Brant said. “So, many times, giving pure oxycodone [with] acetaminophen on the side is one of the best ways to control pain, even though [oxycodone] has an active metabolite.”

While oxycodone is efficacious and has a tolerable AE profile, nurses and other providers should also remember that it may pose a greater risk for substance use disorder compared with other opioid pain relievers.


Finally, fentanyl is a drug that has various pharmacokinetic properties, depending on how it is administered.

For example, a transdermal patch can take up to 12 hours to start working because the drug must penetrate and saturate the patient’s subcutaneous adipose tissue before entering the systemic circulation. “Then, it finally starts working 12 hours later and lasts about 72 hours,” Brant said. “For some patients, however, you have to apply it every 48 hours because they really drain that patch more quickly.” Nurses must remember that transdermal fentanyl’s analgesic effect will likely be delayed in patients who are obese because the drug must saturate a greater amount of adipose tissue.

Clinicians can also give fentanyl via the transmucosal route. That method has a quick onset of action of approximately 5 to 10 minutes, according to Brant, who explained that fentanyl is absorbed through a mucous membrane—in the patient’s mouth, for example. Intravenous fentanyl also takes effect quickly. ;


1. Brant J. All about opioids: calculations and conversions. Presented at: 2020 Oncology Nursing Society Bridge virtual conference; September 8-17, 2020; Virtual. Accessed September 22, 2020. . Nurse Perspective

Judith A. Paice, PhD, RNNorthwestern Medicine, Feinberg School of Medicine

Oncology nurses are instrumental in providing effective cancer pain management. They conduct a comprehensive assessment, develop a management plan with other team members, deliver treatment, educate patients and family members about optimal treatment use, and monitor the regimen’s effectiveness. Of these many roles, providing safe and effective opioid therapy can be the most challenging. Before the patient receives their first dose, the nurse must navigate the patient through a landmine of obstacles, ranging from fear and stigma to difficulties with access and inadequate knowledge. Here are a few strategies to guide oncology nurses, so patients receive optimal care:

1. Establish a functional goal for opioid treatment. Ask patients, “if we do a better job with relieving your pain, what will you be able to do that you do cannot now?” The answer provides an objective measure to determine treatment success. Examples include walking around the block or sitting at the dinner table with family.

2. Demystify “as needed” and long-acting dosing. Explain that the peak effect of most rapid release opioids is not that immediate—usually one hour—so do not delay if pain is beginning to escalate. Explain timing opiate dosing to prevent predictable pain periods.

3. Offer techniques to prevent constipation. Most people are mortified to discuss their bowel habits and they may not volunteer information about having issues until the problem is serious.

4. Define appropriate safe opioid use strategies, including locking in a secure storage area, avoiding other sedating agents, taking the medication as ordered, having nasal naloxone available, and disposing all substances at take-back locations when no longer needed.


Standardized Procedures Improve Fertility Preservation in Cancer Care

By Brielle Benyon

Fertility preservation for women with cancer can be a very involved process, highlighting the importance of a multidisciplinary team. However, many cancer centers do not have a set process in place, which, in turn, can affect the chances of a patient receiving the best possible outcome.

A research team at Froedtert & the Medical College of Wisconsin led by Julia Olsen, MN, RN, CNL, clinical nurse leader, recently created a standardized approach to providing fertility preservation education and services to hematology/oncology inpatients.1

“According to the National Cancer Institute, there are nearly 500,000 cancer survivors of reproductive age in the United States,” Olsen said in her presentation at the 2020 Oncology Nursing Society Bridge virtual conference, held September 8 to 17, 2020.

“We have multiple ways to effectively treat patients with cancer, whether it’s chemotherapy, radiation therapy, surgical interventions, or clinical trials, but we don’t always know how these therapies affect a patient’s fertility. Because of this, we have a duty to provide patients with options for fertility preservation so they can make the best decision for their care.”

The method that Olsen and her team developed includes the following: • Handouts/educational resources

• Structured consultations by designated staff members with standardized documentation

• Coordination with the andrology laboratory and courier services (for patients undergoing sperm cryopreservation)

• Collaboration with the interdisciplinary team

While the plan can be used for both male and female patients, women tend to have a more complicated—and costly—experience.

Women are referred to a reproductive medicine center, where they undergo hormone therapy and an oocyte retrieval procedure, which could delay cancer treatment by 3 to 4 weeks. This process can cost $8,000 to $10,000, with additional annual fees for egg storage.

Men, on the other hand, have the option of sperm cryopreservation (also known as “sperm freezing” or “sperm banking”). Collection can be completed at any inpatient or outpatient site, including a reproductive medicine center, and it does not necessarily delay treatment. The cost is typically less than $500, according to Olsen.

The goal of the project was to standardize how fertility-related information was provided to patients while ensuring they received the best, most up-to-date materials. Olsen wanted to be sure that patients understood the risk to their future fertility associated with their cancer treatment plan so they could make an educated decision about mitigating that risk through fertility preservation procedures.

“Some key takeaways of this new process [are that] pretreatment discussion with patients regarding fertility preservation is best practice and should always be completed. Having a standardized method for providing education and services truly ensures that the patient receives current and accurate information,” Olsen said.

Olsen also explained that the project highlighted some flaws in the system that was being used.

“We have identified some opportunities since beginning this new process,” she said. “The first is that there’s a knowledge gap outside of hematology and oncology. Fertility preservation is not specific to oncology; there may be a need in other areas of the hospital. But there is a lack of knowledge that this service exists and that it could be implemented for other patients in need.”

Looking ahead, Olsen said that the procedures her team developed could also be beneficial in the pediatric setting.

“We’ve also identified that there is an opportunity to collaborate with Children’s Hospital of Wisconsin. Pediatric oncology patients, later in life, will transition to [radiation therapy] for care if necessary.” .


1. Olsen J, Froggatt N. Beyond the birds and the bees: a standardized process for fertility preservation within the hematology/oncology service line. Presented at: 2020 Oncology Nursing Society Bridge virtual conference; September 8-17, 2020; Virtual. Accessed September 18, 2020. .

Symptom Management

More Research Is Needed on Treatments for Symptom Clusters in Cancer Survivors

By Brielle Benyon

Cancer survivors often experience clusters of simultaneous symptoms. Although pain, fatigue, and sleep disturbances are the most common symptom cluster, the majority of interventions applied in randomized controlled trials did not alleviate all 3 of these symptoms, according to the results of a recent systematic review presented at the 2020 Oncology Nursing Society Bridge virtual conference, held September 8 to 17, 2020.1

“Symptom clusters reduce survivors’ quality of life. This is why effective self-management interventions are needed to alleviate symptom clusters,” said Sameena Sheikh, RN-BC, a doctoral student at the University of Miami in Coral Gables, Florida, while presenting her findings. “Oncology nurses need to continue to assess and advocate for effective management of symptoms.”

Sheikh analyzed 10 randomized controlled trials that included a total of 1176 survivors. Effects on pain, fatigue, and sleep disturbances were measured in 3 studies that used exercise interventions, 3 that used a behavioral approach, 2 that used a pharmacological approach, and 2 that used other therapies.

Overall, 40% of interventions were effective in managing the entire symptom cluster (pain, fatigue, and sleep disturbances), whereas 50% relieved 1 or 2 symptoms, and 10% failed to manage any symptoms.

The following interventions resulted in statistically significant and clinically meaningful improvement in the entire symptom cluster:

• Aerobic exercise and stretching that occurred 3 times a week for 9 months

• A behavioral-based cognitive strategy involving imagery, relaxation, and distraction

• Another behavioral intervention, the Valencia model of waking hypnosis with cognitive-based therapy, taught in four 1-hour sessions over 3 months, with skill practice 3 times a day between sessions

• Slow-stroke back massage provided for 10 minutes 3 times per week (on chemotherapy treatment days), for a total of 4 weeks

“Exercise, behavioral, and massage interventions are promising treatments to manage the entire symptom cluster,” Sheikh said.

The only intervention that did not improve any symptoms in the cluster was daily 1-hour cranial microcurrent stimulation, which applies low-intensity currents to the earlobes or scalp.

However, more research is needed in the realm of symptom cluster management so that oncology nurses can provide better and clearer relief recommendations to their patients.

“Nurse scientists researching symptom clusters should provide clarity and consistency on specific [interventions]” Sheikh said.

“For sustained impact on cancer survivors’ well-being and quality of life, more randomized controlled trials are needed [that test interventions] over a [longer] time to ensure reliability and stability in outcomes. This is because symptom clusters may persist and evolve throughout the continuum of cancer survivorship.” ”


1. Sheikh S, Downs CA, Anglade D. A systematic review on interventions for managing a symptom cluster (pain, fatigue, and sleep disturbances) during cancer survivorship. Presented at: 2020 Oncology Nursing Society Bridge virtual conference; September 8-17, 2020; Virtual.Accessed Oct. 1, 2020. .


Nurses’ Role in Managing Cardiotoxicity in Cancer Survivors

By Brielle Benyon

As the number of cancer survivors continues to grow, it is imperative that clinicians closely monitor therapy-related cardiotoxicity during and after completion of cancer treatment. Cancer survivors, particularly those treated with anthracyclines and/or trastuzumab (Herceptin), may be at increased risk of damage to the heart and vascular system that may lead to premature cardiovascular disease. Specialists in the growing field of cardio-oncology focus on the cardiovascular health of this patient group.

“As advanced practice nurses, it’s important to understand current clinical guidelines for cancer survivors in order to educate and support survivors,” said Jacqueline B. Vo, PhD, MPH, RN, a cancer prevention fellow at the National Cancer Institute in Rockville, Maryland.

“Both anthracyclines and trastuzumab can cause left-sided heart failure. The risk of heart failure increases significantly when both of these drugs are given together,” she said.

In her research, which was presented at the 2020 Oncology Nursing Society Bridge virtual conference, held September 8 to 17, 2020, Vo analyzed survivorship guidelines regarding cardiovascular care of cancer survivors.1 She looked at recommendations published by 5 leading organizations: the American Society of Clinical Oncology (ASCO), American Cancer Society (ACS), European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN), and American Heart Association (AHA).

AHA, ASCO, and ESMO all recommend baseline echocardiograms of the left ventricular ejection fraction for patients receiving anthracyclines and/or trastuzumab. Additionally, NCCN deems low baseline ejection fraction (<55%) a risk factor for cardiotoxicity.

AHA, ASCO, and ESMO all recommend regular cardiovascular screening (for example, every 3 months) while patients are undergoing cardiotoxic treatment, and these groups plus NCCN recommend screening 1 year after a patient completes treatment.

Survivorship guidelines published by ASCO in collaboration with ACS reference the NCCN cardiotoxicity guidelines but also focus on monitoring lipid levels, cardiovascular monitoring, and patient education on healthy lifestyles.

Only 1 organization, ESMO, recommends long-term monitoring (at 4 and 10 years after treatment completion).

Vo said that nurses can play a key role in ensuring that their patients receive echocardiograms when recommended or necessary. Additionally, it is important for nurses to be aware of not only patients’ treatment history but also aspects of their lifestyles that could contribute to the development of heart problems down the line.

“We also want to provide survivorship care that is tailored to the patient, including modifying the risk factors and also educating the patient on risk factors,” Vo said. Changes survivors can make to mitigate their risk include smoking cessation, maintaining a healthy weight, and getting enough physical activity.

As more clinicians understand the impact of cancer treatment on the heart, better interventions and prevention strategies can be crafted. There are ongoing studies examining lifestyle interventions such as improved physical activity and diet, as well as pharmacologic studies evaluating the role of drugs such as angiotensin-converting enzyme inhibitors in preventing cardiotoxicity.

“There’s a growing quantity of cardio-oncology clinics, specifically in academic medical centers,” Vo said. “With this, there’s also a need for nurses to be trained in cardiology and cardio-oncology.”


1. Vo JB, Dimond E, Shelburne N. Reviewing clinical cardiovascular guidelines for adult cancer survivors: implications for oncology nursing practice. Presented at: 2020 Oncology Nursing Society Bridge virtual conference; September 8-17, 2020; Virtual. Accessed Sept. 20, 2020. 2607356/vo_reviewing-clinical-cardiovascular-guidelines-for-adult-cancer-survivors-implications-for-oncology-nursing-practice-self-recording-on-demand

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