Clinical Insights: June 2017


CE lesson worth 1.0 contact hour that is intended for advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients.

Release Date: June 22, 2017Expiration Date: June 22, 2018

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 articipate 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 patientswith cancer


Physicians’ Education Resource®, LLC is approved by the California Board of Registered Nursing,Provider #16669 for 1.0 Contact Hours.


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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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®.

ONS 42nd Annual Congress | Immunotherapy

Closing the Immunotherapy Knowledge Gap With Technology

Lauren M. Green

Seeing significant growth in the number of patients treated with immunotherapy within their healthcare system, a multidisciplinary team of nurses and other practitioners at the Smilow Cancer Hospital at Yale-New Haven led a multipronged effort leveraging their electronic medical record (EMR) system to improve the management of these patients across all levels of the healthcare system.

Monica Fradkin, RN, BSN, MPH, OCN, presented the findings thus far at the ONS 42nd Annual Congress. A working group was convened last year after seeing immunotherapy patients at the Yale-New Haven network’s clinics increase to 430 from just 9 in 2013.

Fradkin said they discovered wide variation in how patients on immunotherapies were managed and a lack of staff knowledge of side effects. One problem involved when these patients go to the emergency department (ED) and are seen by a nononcology provider, or visit a primary care physician (PCP) with subtle symptoms that may have been identified earlier had the oncologist been consulted.

To address these gaps, a multidisciplinary group of advanced practice providers, nurses, pharmacists, and consulting expert physicians gathered information, set goals, and developed the educational content to included in the patient’s EMR. They also identified and evaluated the standard patient education materials on immunotherapy. “We wanted to make sure that [our program] crossed everyone who was going to be in the room,” and addressed all of their needs, Fradkin said.

The team’s educational program explained the role of the immune system in cancer, the drugs’ mechanism of action, and their specific side effect profiles. Advanced practice providers served as faculty.

The group found that available patient education resources were lacking. “We liked the idea of an information card that patients could hand to their PCP, or if they did go to the ED, to alert the staff,” said Fradkin. The working group is also exploring how to incorporate an interactive patient video into My Chart.

Optimizing EPIC-EMR capabilities is another goal of the initiative, so that immunotherapy information is distributed to all providers these patients are likely to encounter. They created a Best Practice Alert, noting that the patient is receiving immunotherapy and directing the provider to call the oncologist before making any treatment decisions. They also added an “FYI” tab at the bottom of the record with helpful information to guide anyone caring for the patient.

Telephone triage guidelines also had to be revisited. Examples of some of the questions added include: Do you have abdominal pain? Are you cramping, experiencing nausea or vomiting? Do you have blood in your stools? Answers to these questions help the practitioner to triage the patient.

An ambulatory-specific flow sheet was created specific to the organ system, so clinicians know what to look for. Bowel movement patterns, for example, illuminate colitis risk. O2 stats when patients are resting versus walking can be clues to pneumonitis.

“You have the ability to trend when you document in an electronic medical record, and when you do that, you can actually see subtle changes that you may not realize from encounter to encounter, if you’re not looking back at previous encounters.”

And now that the staff has these tools, Fradkin said, “We have the ability to standardize how we perform assessments and also standardize documentation.”

In addition to improved provider and patient education, the group wants to measure if their work impacts outcomes, such as reduced visits to the ED and reductions in the number of serious adverse events.

Fradkin highlighted several takeaways for other cancer center staff looking to enhance their immunotherapy programs: “We learned that what we thought would be a ‘quick, put some education together’ [activity] actually takes a long time, and it took a large group of us working to get this done.”

“We also learned that issues are interlocked. The Best Practice Alert that we thought would make so much sense for the [non-oncology] providers by sharing what we learned, actually impacts the whole system, so there were multiple barriers and layers for approval.”

Above all, said Fradkin, “Collaboration across the disciplines was the key to the success of this program, and that is how we have been able to take it to the next step.”

ONS 42nd Annual Congress | Oncology Practice

Implementing a New Core Measure of Sepsis

Katie Kosko

Identifying early signs of sepsis can help save lives. However, this comes with many challenges, as sepsis can present with atypical signs and symptoms in patients with cancer. Brenda Shelton, DNP, RN, APRN-CNS, CCRN, AOCN, an oncology nurse at The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins in Baltimore, discussed the intervention she and her colleagues implemented at their center during a presentation at the ONS 42nd Annual Congress.

Sepsis is among the most common causes of nonmalignant deaths in oncology patients— occurring in 14% of patients with cancer; mortality can be as high as 30% to 40%. The stages of sepsis include: systemic inflammatory re-ponse syndrome (SIRS), sepsis, severe sepsis, and septic shock. Shelton said that the least accurate SIRS criterion in patients with cancer is heart rate, with the strongest indicator being respiratory rate above 20 breaths per minute.

Recommendations for surviving sepsis in the first 3 hours is to begin by screening a patient at the first encounter—be it triage or outpatient— and if there is a positive screening, order blood cultures and a lactate test. A nurse should also assess organ function and give the first antimicrobial within the first hour of the decision that the patient is infected.

In addition, oxygen should be given if saturation is not above 90%, and a fluid bolus if the patient is hypotensive or has a lactate level higher than 2 mmol/L. In the next 3 hours, there should be assessment of the source, mean arterial pressure should be above 65 mm, and if the patient has remained hypotensive despite fluids, vasopressors should be initiated.

The team from Hopkins revised current Core Measure Sepsis screening criteria in order to better identify sepsis among patients with cancer, and help lower the number of false positives. Its criteria now include: body temperature less than 35.5 ̊C and more than 38.0 ̊C; heart rate greater than 100/min; neutropenia; elevated glucose in the absence of diabetes; altered mental status; and mottling.

Since modifying the criteria, Hopkins has not missed any cases of true sepsis; it has reduced hypotension from 50% to 30%, and significantly lowered cases of severe sepsis to 12%.

Shelton stressed the importance of fast action when it comes to assessing a patient for sepsis. “I am a strong believer that timely antibiotics are the key intervention. For every hour that you delay beyond the first 60 minutes, mortality increases to about 7.6%. You don’t really know who is going to become sicker at hour 2.”

Reducing Patient Wait Times in the Infusion Room

Lauren M. Green

Along with the many challenges that come with cancer treatment, waiting a long time in the infusion chair before receiving chemotherapy or other anticancer IV medications should not be one of them. A team of nurses at Johns Hopkins Hospital stepped up to the challenge with an action plan to address this problem with a focus on mixing standard chemotherapy doses ahead of time and preinfusion patient screening to make sure they’re appropriate to treat the next day.

And vital to this effort, according to participants, is the expert guidance on workflow provided by an “ACE” interprofessional team of more experienced nursing and pharmacy staff.

Mary Beth Collins, MSN, RN, presented the findings of the ACE (Ambulatory Clinical Evaluation) project during a podium presentation at the ONS 42nd Annual Congress.

The project is an outgrowth of Hopkins nursing staff’s longstanding interest in improving the patient experience in the ambulatory setting and especially in reducing patient infusion wait times to no longer than 30 minutes beyond their scheduled appointment.

When nurses started examining the problem during the period between November 2014 to October 2015, they found wait-time ranges from 0 to a maximum of 525 minutes, with a mean wait time of 48 minutes.

In addition, they discovered that preparation for next-day patient visits was inconsistently performed by the patients’ primary nurses, and in the absence of a structured process for prescreening patients for their infusion, pharmacy staff was reluctant to prepare the drugs ahead of time.

Primary nurses at Hopkins improved the process, with the help of the 4-member ACE team of veteran nurses and pharmacists to facilitate care coordination:

Require that treatment orders and notes are submitted 48 hours in advance of the patient’s appointment

Review of patient orders, notes, and laboratory values by ACE team members

Telephone patients at home 1 day before their scheduled appointment, using a standardized checklist specific to the drug to confirm the patient is fit for the planned treatment.

For example, a patient scheduled for an adriamycin/cytoxan infusion would be asked questions about such symptoms as shortness of breath, abnormal heart rate, ringing in the ears, any falls, swelling, or rashes, and eating and drinking patterns. If the review is successful, chemotherapy mixing orders are sent to the ACE pharmacy team for a second safety review, so that appropriate medication can be prepared the evening before the patients’ scheduled infusion appointment the next day.

Staff has a list of ACE drug eligibility and a timetable for how long certain drugs can be prepared in advance, based on whether they are extended or short stability.

“The ACE program has changed the treatment experience for providers, nurses, and our patients,” reported Collins. “It has reduced patient wait time from a baseline of 49.7 minutes to 32.7 minutes after the ACE intervention.”

Other benefits include “ensuring quality, value, and a patient-centered experience” and Collins credits this to the standardized approach developed to evaluate patients before treatment.

She added that these improvements were achieved without the addition of full-time equivalent staff.

ONS 42nd Annual Congress | Supportive Care

Preventing and Treating Oral Mucositis With Laser Therapy

Lauren M. Green

Oral mucositis (OM) is one of the most debilitating side effects of many anticancer therapies. Positive results from the use of low level laser therapy (LLLT) inspired a team of nurses at UPMC Shadyside in Pittsburgh to develop an intervention to

help a group of colleagues not only learn how to deploy the laser treatment, but also to better assess mucositis and educate patients on the importance of oral hygiene and other prophylaxis.

Erin Bartell BSN, CCRN, BMTCN, who practices in the hospital’s stem cell transplant unit, reported the project’s findings at a podium presentation at the ONS 42nd Annual Congress.

After seeing evidence of how LLLT—which was being used routinely in the hospital’s radiation oncology department—improved quality of life for patients with head and neck cancer, physicians sought to have the treatment available for inpatients. However, the machines are expensive and practitioners need training to use them.

Bartell explained that their project was made possible because a beloved former staff member and oncology patient at the hospital, Barbara King, who was passionate about alleviating the pain of OM for patients like herself, secured a grant for the purchase of 2 additional LLLT machines.

Patients who have OM may have to suspend or delay treatment, need opioid analgesia, or require enteral/parenteral nutrition. If left untreated, OM ulcerations can lead to life-threatening infections in patients who immunocompromised, such as those undergoing hematopoietic stem cell transplant. It was a group of these inpatients at UPMC Shadyside, being treated with busulfan, who received patient education and LLLT for this study.

For the intervention, 11 “super users” were selected for LLLT training so they could treat patients at the bedside. In addition to training from THOR, the device manufacturer, these nurses also received education to improve their OM assessment and patient education skills.

Patient Education to Prevent Oral Mucositis

“Because most of our nursing staff has about 2 years or less experience, it was really important for them to understand the risk factors for oral mucositis,” Bartell noted. Additionally, “they don’t necessarily understand the severe impact oral mucositis can have on a patient’s life, so we wanted them to understand that [this adverse event] can modify, delay, or even suspend treatment.”

Nurses received education on the chemotherapy doses and regimens like busulfan that pose the highest risk for OM, along with patient risk factors, such as poor oral hygiene, impaired salivary function, genetic factors, and use of alcohol and tobacco. Patients were encouraged to practice proper oral care, with nurses assisting them with oral hygiene techniques as needed (Box).

The nurses also instructed patients to report any changes in their oral health, especially pain. “A lot of patients are a little embarrassed talking about this,” Bartell said. “It’s really important for nurses to educate patients and really get [the patients] motivated about doing their own oral care—3 times a day after every meal and before bed.”


• Patients should be counseled to do the following:

• Perform proper oral hygiene techniques

• Avoid irritants such as alcohol, including high-alcohol mouthwash, and tobacco

• Use a sodium bicarbonate—based toothpaste, a soft toothbrush, and a normal saline swish*

• Stay hydrated

• Practice oral care, 3 times a day after every meal and before bed; ask for assistance when needed.

*Biotene is also available for patients who experience dry mouth.

To provide an objective way for the nurses to document their data, the researchers added an e-record treatment form. The form pops up as part of the e-charting, Bartell said, where nurses can easily enter information on the appearance of the oral cavity, location of any ulceration or abnormalities using the National Cancer Institute-Common Terminology Criteria for Adverse Events (NCI-CTCAE) Grading Scale.

The report also includes results of the pain assessment, their patient education, and the treatment given.

Low Level Laser Therapy: How Does It Work?

Bartell said that the THOR LLLT system is simple to use, involving both an extraoral and intraoral probe. When it’s the patient’s first encounter with the device, the nurses provided extensive education:

“We really wanted them to understand why they were receiving the treatment and if they had any questions,” said Bartell.

After the patient is in a comfortable position, and aided by flashlights available in every room of patients on the study, the nurse conducts a thorough oral and pain assessment. Nurses and patients wear protective goggles for the procedure.

The extraoral probe is positioned close to the cheek but not touching it, to target the buccal area. After both cheeks are done, with the probe in front of the patient’s mouth, the nurse has the patient stick out the tongue, and then targets the bilateral sides of the tongue and behind the lips with the probe, which, Bartell noted, is a common location for mucositis.

The intraoral probe is then angled toward the soft palate. “If the patient develops ulcerations during the hospital stay, we then target those areas specifically with the intraoral probe.”

Each treatment area is done for 1 minute at a time, with a total treatment time no longer than about 15 minutes—and that includes the patient education and LLLT administration, Bartell said.

A Model for Use in Other Settings

“Preliminary qualitative assessments through patient interactions suggest that patients’ quality of life is improved through the use of LLLT,” the researchers noted in their abstract, and they recommended that OM education be part of the nursing orientation for use of LLLT.

“This education model and choice of therapy can be further expanded to other oncology populations for treatment and prevention of OM.”

Gum Chewing to Prevent Postoperative Ileus

Beth Fand Incollingo

Intestinal blockages after cancer-related abdominal surgery are common enough to require between 4750 million and $1.5 billion in treatment every year in the United States.

Between 3% and 32% of patients in this population experience postoperative ileus (POI]), which is caused by decreased gut motility; 1 episode can cost up to $15,000 to treat, according to the lead author of a pilot study. That’s not to mention what the authors described as “immeasurable pain and suffering for patients.”

What if there was a simple, noninvasive, and inexpensive way to prevent POI in some patients? The pilot study conducted at the University of Texas Southwestern Medical Center in Dallas suggests there is: chewing gum.

The study’s authors, led by Linda Chan, BSN, RN, OCN, examined a 2015 meta-analysis of 81 studies and 9072 patients which found that gum chewing had decreased the time to first flatus by 10.4 hours, the time to first bowel movement by 12.7 hours, and length of hospital stay by 0.7 days, Chan reported.

Researchers have elucidated some reasons for the effectiveness of gum chewing in these patients, Chan said: It stimulates the vagus nerve that enervates the gut, and it produces saliva, which causes the gut to secrete gastric hormones. She added that studies show that sugar-free gum may be preferable in preventing POI. “The sweetening agents used in sugar-free gums are sorbitol or mannitol, which creates an osmotic effect, or diarrhea,” she said.

In the pilot study in a 32-bed surgical oncology unit, the team of 3 nurses considered how gum chewing versus no gum chewing affected POI status in patients with cancer hospitalized after abdominal surgery.

When patients underwent abdominal surgery, nurses worked with attending physicians to add a “may chew gum” order to their charts, when appropriate. Regardless of their prescribed diet, patients were free to participate unless they were disoriented or otherwise unsafe to chew gum. Doctors’ medical orders were coupled with patient education in the form of packets explaining POI and that gum chewing might prevent it. Participation was voluntary, with nurses supplying regular or sugar-free gum to those who opted into the program. Gum chewing status was recorded in patients’ electronic health records.

Patients were advised to start chewing gum 6 hours after surgery or when fully awake, 4 times a day and as desired. Nurses offered gum when patients were alert, oriented and safe to chew it, and ceased offering it after each patient’s first postoperative bowel movement. Nurses monitored patients’ gum-chewing status and discussed it during between-shift huddles, in bedside reports, and on hospital-room white boards. Gut motility was measured via x-ray.

From April 1 through August 31, 2016, 159 patients underwent abdominal surgery; 74 chewed gum and 85 did not. Fifteen patients developed POI, and 5 (6.8% of the overall group), had chewed gum. Ten (11.8%) had not.

The nurses plan to follow up on these results with a retrospective study comparing current POI rates in this patient population with those recorded before the unit’s practice change in favor of gum chewing

Neutropenic Diet Can Be Eliminated With No Rise in Infecions

Beth Fand Incollingo

The neutropenic diet is a common strategy in cancer care. Yet no scientific evidence exists that it helps the population it's meant to protect — those who face an increased risk of infection because they are experiencing neutropenia after chemotherapy or other cancer treatment.

That finding, based on a literature review, was shared by Chelsea Nee, BSN, RN, OCN, of UPMC-Shadyside in Pittsburgh, during the ONS 42nd Annual Congress. Based on that data, Nee and colleagues launched a quality improvement project at their facility that tested the elimination of the neutropenic diet in patients with cancer.

“In a literature review that included two meta-analyses, we found that not one study has ever shown a reduction in infection or mortality rates,” Nee said in a poster and discussion detailing the improvement project.

Patients on the neutropenic diet are asked to avoid foods that might carry bacteria, such as fresh fruits and vegetables; unpasteurized juices, milk, honey, yogurt, and cheese; cheese that is soft or contains molds; cold-brewed tea; raw oats and nuts; and deli meat and sushi.

Doctors began prescribing it to patients with cancer in the 1970s, after a study was published that included it, among other protective measures, as a strategy to support the well-being of patients who had undergone stem cell transplant, Nee said. The study “showed a decrease in infections,” she said, “but there were other interventions, too,” with no specific evidence that the neutropenic diet was a contributing factor.

Nee said that it took about 1 year to get the quality improvement project going, as clinicians learned about it and prepared to remove the diet from electronic health records. They were taught to ask patients with cancer to eat regularly but engage in standard safe food handling practices, including washing hands, washing fresh fruits and vegetables carefully, cooking meat to temperature, and refrigerating perishables. For stem cell transplant patients only, staff members replaced the neutropenic diet with one that includes many of the same restrictions, but allows fresh fruits and vegetables, Nee said.

A total of 5773 patients included in the project were admitted to the hospital between December 1, 2014, and July 31, 2016. The neutropenic diet was officially removed from clinical practice there on May 13, 2015. Data on the incidence of bacteremia, clostridium difficile infections, and pneumonia were collected before and after the program was launched, and did not show any increase in infections after the neutropenic diet was eliminated. In fact, patients who adhered to the neutropenic diet were more likely to develop pneumonia, they found.

Based on those results, the entire UPMC healthcare system has eliminated the neutropenic diet from practice.

“Oncology patients have a difficult time meeting nutritional requirements, so the liberalization of diet restrictions has improved the selection of what they can eat,” the authors concluded.

ONS 42nd Annual Congress | Palliative Care

Lessons from the NICO: Hospital-Based Nursing Protocol Supports Cancer Caregivers

Lauren M. Green

Although studies show that patients with cancer would prefer to be cared for at home at the end of life, the majority still die in the hospital, many in intensive care. Despite this fact, much of the knowledge about supporting their families is drawn from research in the outpatient and hospice setting, leaving a gap in bereavement support for these caregivers when their loved one is hospitalized.

Knowing that parents of critically ill infants in the neonatal intensive care unit (NICU) receive a specific set of nursing-based supports, a team of nurses at UC Irvine Health in Huntington Beach, California, set out to find out whether lessons from the NICU can be applied in the inpatient oncology setting and developed an evidence-based protocol modeled on the NICU experience.

“The perinatal and OB world has had a protocol to follow in large centers to support parents who have lost a child,” based on a decades-long awareness that parents need nurses’ support during the time of a child’s death, noted lead author Deborah Boyle, MSN, RN, AOCNS, who presented the research at the ONS 42nd Annual Congress.

Boyle said that this support involves a number of interventions; for example, their chart is flagged and a plaque is placed outside the mother’s room acknowledging the loss, so that anyone who enters the room does so with sensitivity. In addition, nurses help to fill memory boxes to send home with the parents that include mementos from the baby, such as footprints, handprints, locks of hair, and clothing/blankets.

“The protocol they use is very prescriptive in terms of the range of interventions that should be provided to these acutely grieving parents,” Boyle explained. “Parents are asked if they want to have time alone holding the baby; do you want pictures of the baby; do you want to help us bathe the child, dress the child?” Parents will have different comfort levels for the nature of the interventions, Boyle added, but this approach offers an array of opportunities for support.

For years, Boyle had an interest in translating best practice from this model to the adult oncology setting. When working at a hospital in Virginia earlier in her nursing career, she joined a social worker in running a group for families titled “Good Grief”: “We asked the families what the nurses did for them at the time of death and what they would have wanted, if they had another chance to enact this experience?” said Boyle. The literature lacked evidence specifically focused on the nurse’s role in the acute care setting, she noted.

What do Family Caregivers Need?

Based on hospice nursing literature and her own experience as a family caregiver in a hospice situation, Boyle and colleagues developed a 13-item survey for patients’ families to find out what families wanted and to help guide a new bereavement protocol for adult oncology inpatients.

Specially trained staff nurses interviewed individuals who had a family member die at their hospital. Interviews were also conducted with non-native English speakers. The questions were framed around if a nursing intervention was employed, and if not, would families want it:

  • Did the nursing staff offer you physical support (eg, hold your hand, embrace, and sit with you)?
  • Did the nurses ask if you wanted them in the room with you and your loved one or whether you wanted privacy?
  • Did they encourage you to spend time with your loved one and say goodbye before they died?
  • Did they explain to you what was happening during the dying process to help you understand what you were seeing?
  • Did they respect your wishes and needs (eg, cultural and religious beliefs)?
  • Did they voice concern over your well-being, such as encouraging you to take care of yourself?
  • Did they offer you a chance to sit alone with, and care for, your loved one after they died, (ie, help the nurses care for your loved one’s body)?
  • Did they send you a card to let you know they were thinking of you?

Nurses who had contact with patients at the end of life received the same survey. Boyle reported that a comparison of the results revealed “a discrepancy between what the families desired and what interventions the nurses considered helpful.”

"The nurses underestimated the importance of having us offer to pray with them, to ask them if they wanted to help with the final care of their loved one’s body, and the importance of sending a sympathy card."

A Family Bereavement Support Protocol

These findings set the stage for the team’s Acute Family Bereavement Support Protocol for acute care nurses at the bedside, including:

  • Room signs
  • Offering families a menu of support options (eg, desire for privacy, helping with the final nursing care after the loved one dies)
  • A script to help the nurse share advice with family members about how to say goodbye
  • Creating a memory keepsake, including, eg, taking a photograph of the patient’s hands
  • Performing a postdeath “honoring ceremony” (including essential oils)
  • Helping to gather the patient’s belongings and escorting the family out of the hospital
  • Establishing a process for signing and sending a sympathy card 1 month later

The timing for implementing the interventions was at the discretion of the nurse, depending on the patient’s status; social work and spiritual services also were consulted. Relatively simple steps, Boyle said, like protecting privacy by keeping the door shut, ensuring enough chairs are in the room, and providing a parking pass the day the patient died, also were part of the intervention. “There are many, many options for supporting families,” she stressed.

Study authors reported in their abstract that the project is in the pilot phase. The team plans to call 20 family members for their evaluation of the intervention, but that, “preliminary results have been overwhelmingly positive.”

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