Clinical Insights: September 2015


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


The overall goal is to update the healthcare professional’s knowledge of cancer detection and prevention and to understand current and new research regarding state-of-the-art care for those with or at risk for cancer.


Intended for advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients.


Upon completion, participants should be able to:

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


Dannemiller is approved by the California Board of Registered Nursing, Provider Number 4229, for 1.0 contact hour. CBRN credit is not accepted by the Michigan and Utah State licensing boards.


The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.


  • Read the articles in this section in its entirety.
  • Go to
  • Complete and submit the CE posttest and activity evaluation.
  • Print your Certificate of Credit.

This activity is provided free of charge to participants.

Gynecologic Malignancies

Chemotherapy Dose Reductions Yield Worse Survival in Women With Ovarian Cancer

Lauren M. Green

Failure to follow professional practice guidelines for weight-based chemotherapy dosing can lead to poorer survival in women with ovarian cancer, according to a new study finding that patients who experienced an average dose reduction of ≤85% had a 35% higher risk of mortality than those who received normal (85% to 100%) dosing. (JAMA Oncol. 2015; doi: 10.1001/jamaoncol. 2015.1926).

Chemotherapy dosing is generally based on a patient’s weight. However, dosing levels can vary considerably, in part because providers opt not to provide doses over a certain level due to worries over increased toxicity.

Investigators with the Rutgers Cancer Institute of New Jersey and the Kaiser Permanente Northern California (KPNC) Division of Research did a cohort study involving 806 women at KPNC receiving first-line treatment for their epithelial ovarian cancer with adjuvant carboplatin and paclitaxel. Primary study outcomes were overall and ovarian cancer—related mortality. Data were gleaned from electronic medical records and the KPNC Mortality Linkage System. Approximately 30% of participants were obese (BMI ≥30), and 31% were overweight (BMI = 25-29); fewer than 3% were underweight (BMI <18.5). Researchers found that obese women received less paclitaxel and carboplatin per kilogram of body weight and lower dose intensity when compared with women of normal weight.

Overall, lower dose intensity yielded worse outcomes—regardless of BMI&mdash;and was an independent predictor of ovarian cancer mortality. Researchers noted that the effect of dose reduction was actually strongest among normal-weight women, and this finding held true even after accounting for such diagnostic and prognostic factors as posttreatment CA125 levels, disease stage, and comorbid conditions.

“We found that for each body mass index category, ovarian cancer patients with dose reduction experienced a poorer survival rate,” said lead study author Elisa Bandera, MD, PhD, epidemiologist at the Rutgers Cancer Institute of New Jersey, in a statement.

High BMI was the strongest predictor of dose reduction. Women who were obese class III (BMI ≥40) received 38% lower doses in milligrams per kilogram of paclitaxel and 45% lower doses of carboplatin, compared with normal-weight women. For these women, the mean average relative dose intensity (ARDI) was 73.7% compared with 88.2% for their normal-weight counterparts. An ARDI of <70% was linked to worse overall survival and ovarian cancer—specific survival. Although women who were obese at diagnosis appeared to have better survival rates, that advantage disappeared when their chemotherapy dose was reduced.

Endometrial Cancer Rates Continue to Rise

Lauren M. Green

Rates of endometrial cancer continue to increase among all racial and ethnic groups, but they’re rising faster among non-Hispanic black women who also have poorer outcomes when compared with their white, non-Hispanic counterparts, according to a new study (Cancer Epidemiol Biomarkers Prev. 2015; doi: 10.1158/ 1055-9965.EPI-15-0316).

Endometrial cancer is the most commonly diagnosed gynecologic cancer in the United States, and incidence rates have been rising for many years, according to the study’s lead author Michele L. Cote, PhD.

Cote, an associate professor of oncology at the Barbara Ann Karmanos Cancer Institute and Wayne State University School of Medicine in Detroit, said that her research team launched this study to find out whether these increases in incidence and mortality are equally distributed by race/ethnicity and endometrial cancer subtype.

The researchers analyzed endometrial cancer incidence and mortality data from the SEER database, based on 120,513 cases of the disease diagnosed from 2000-2011. Over the 12 years studied, endometrial cancer incidence rates increased fastest, at 2.5% per year, among non-Hispanic black women and Asian women. But for non-Hispanic black women their rates of all the aggressive endometrial cancer subtypes (eg, clear cell, serous, high-grade endometriod, and malignant mixed Mullerian tumors) were 1.5-fold higher than those for non-His- panic white, Asian, and Hispanic women.

Analysis of overall 5-year survival rates showed that non-Hispanic black women had poorer survival at every stage of diagnosis, regardless of endometrial cancer subtype, compared with non-His- panic white women, whereas 5-year survival rates were similar or higher among Asian and Hispanic women compared with non-Hispanic white women.

Colorectal Cancer

Study Finds Shorter Survival for Thin Patients With Colorectal Cancer

Virginia Powers, PhD

Although having a high body mass index (BMI) is associated with a higher risk for colorectal cancer, patients who are thinner may not do as well after treatment for metastatic colorectal cancer (mCRC), according to new research reported at the recent 2015 World Congress on GI Cancer. Abstract LBA-01

“Contrary to our hypothesis, patients who had the lowest BMI were at risk for having the shortest survival,” said lead author S. Yousuf Zafar, MD, associate professor of medicine at Duke University School of Medicine, Durham, North Carolina.

“In this case, patients with the lowest body weight—people who had metastatic colon cancer and a BMI of less than 25&mdash;were at the highest risk.”

“This effect persisted after adjusting for study, age, ECOG performance status, gender, and hypertension. We did not see any relationship between BMI and progression-free survival.”

The results surprised researchers, who expected obese patients to respond more poorly to treatments for Stage IV colorectal cancer due to their increased risk of developing the disease and having it come back. Additionally, there is some evidence that many obese patients also receive less-than-optimal doses of cancer drugs, or have other health problems that complicate recovery. According to guidelines, a healthy adult’s BMI ranges from 18.5 to 24, whereas a BMI below 18.5 is considered underweight.

Researchers examined data pooled from 6128 patients in the United States and Europe who had previously been untreated for their mCRC and who were included in four different registry studies. Their average BMI at the start of cancer treatment was 25.3, considered slightly overweight, and all patients received bevacizumab with chemotherapy in their treatment.

The study’s primary endpoints were overall survival (OS) and progression-free survival (PFS).

Median BMI for all patients was 25.3 kg/m2 (interquartile range [IQR], 22.6-28.7). BMI was divided into five categories: <20 (n = 532); 20 to 24 (n = 2328); 25 to 29 (n = 2119); 30 to 35 (n = 821); and ≥35 kg/m2 (328).

Although PFS was similar across baseline BMI categories, investigators found a difference in OS. Patients with BMIs <25, 25 to 29, 30 to 35, and ≥35 kg/m2 demonstrated a median PFS of 10.0, 10.6, 10.5, and 10.9 months, respectively.

The median OS in the same four respective BMI ranges was 21.1, 23.5, 24.0, and 23.7 months.

“Proportional hazards models confirmed that low BMI was associated with shortened OS after adjusting for potential differences in baseline characteristics,” commented Zafar.

According to a proportional hazard model using BMI as a continuous variable, a BMI increase of 5 kg/m2 was associated with a decrease in the risk of death (hazard ratio [HR], 0.911; 95% CI, 0.879-0.944).

“I see this study as hypothesis-generating and a basis for a randomized, controlled study,” said Zafar during a question and answer session.

The role of high BMI has only recently been evaluated in mCRC, revealing obesity as a risk factor for developing colon cancer. “Although high BMI has been associated with increased risk of colorectal cancer, little is known about how BMI impacts outcomes for patients already diagnosed with mCRC,” remarked Zafar.

“It’s possible that the lowest weight patients may receive adequate first-line treatment but then are too sick to receive subsequent lines of therapy. That may be where we can focus more attention on improving their outcomes.”

Nurse Perspective

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

John Theurer Cancer Center Hackensack, NJ

The obesity-cancer connection, or specifically the obesity-colon cancer connection, has been well-documented for several years now. Several studies have shown that obesity influences the risk of developing colon cancer. Then, in 2010, a study done at the Mayo Clinic also found that obese patients with colon cancer are at higher risk of cancer recurrence or death. Armed with this information, we have been dogmatic in our practice in preaching the importance of maintaining a healthy BMI at the completion of adjuvant chemotherapy. We also refer all of these patients to our registered dietician for counseling regarding a healthy diet.

So, imagine my surprise (dare I say shock) when I read this study. Patients with the lowest BMI were at risk for the shortest overall survival? This seems to fly in the face of our understanding of the relationship between obesity and colon cancer. For example, one hypothesis is that increased levels of insulin or insulin-related growth factors in obese people may promote the growth of colon cancer. This theory, however, would not apply to the low BMI patient. The authors, too, were unable to offer an explanation, although they did propose a theory which could be the basis of a randomized controlled study. I look forward to those results.

In the meantime, we should continue to encourage ALL of our patients to maintain a healthy BMI. This means not only encouraging our overweight patients to lose some weight but also encouraging our underweight patients to gain some weight. While some of the side effects of chemotherapy, including nausea and taste changes, can make this difficult for many patients, we should continue to employ strategies to help our patients be as healthy as they can and achieve the best possible outcomes from their treatment.

We are very lucky in our center to have oncologists, APN’s, RN’s, and RD’s working together as a team toward this end...or should I say our patients are lucky? However, as we stress to our patients, THEY are the most important team member. As most oncology RNs can attest to, loss of control is one of the biggest stressors for patients diagnosed with cancer and undergoing chemotherapy. Taking control of their diet is one thing that is within their control. My experience is most patients want to know what they can do to “improve their odds.” By educating them, we empower them, which generally leads to a better experience for both patients and their caregivers. And isn’t that why we do what we do?

Colorectal Cancer

Expanded Access Program Confirms Benefits of Regorafenib

Virginia Powers, PhD

Findings from a large expanded access program (EAP) have confirmed the efficacy and safety of regorafenib in patients with previously treated metastatic colorectal cancer (mCRC), according to findings presented at the 2015 World Congress on GI Cancer. Abstract LBA-05

In the phase IIIb EAP, which was labeled CONSIGN, the estimated progression-free survival (PFS) with regorafenib was 2.8 months. These data were consistent with the phase III CORRECT trial, which was instrumental in the FDA approval of regorafenib in September 2012. In this study, regorafenib demonstrated a median PFS of 2.0 months compared with 1.7 months with placebo (hazard ratio [HR], 0.49; 95% CI, 0.42-0.58; P <.0001). Adverse events (AEs) were similar between the two studies.

“Today we report on safety and progres- sion-free survival in a large cohort of patients that more closely resembles daily clinical prac- tice than the pivotal registration trial,” comment- ed Eric Van Cutsem, MD, PhD, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium.

The CONSIGN trial enrolled 2872 patients who progressed after approved standard therapies for mCRC. The EAP enrolled patients from 188 sites located in 25 countries. Patients were administered regorafenib at 160 mg once daily for the first 3 weeks of each 4-week cycle until disease progression, death, or unacceptable toxicity.

PFS per investigator assessment was the only efficacy variable assessed, with safety as the primary endpoint of the study. The estimated PFS was similar regardless of KRAS wild type and mutant status, at 2.8 and 2.5 months, respectively.

As of data cutoff on January 2, 2015, data from 2864 patients receiving regorafenib were included in the safety analysis. The median patient age was 62 years. KRAS mutations were identified in 51% of patients, and nearly all patients (96%) had received ≥2 prior regimens for metastatic disease.

Regorafenib-related AEs leading to treatment discontinuation occurred in 266 patients (9%), and AEs leading to treatment modification occurred in 1732 patients (60%).

Regorafenib-related AEs of any grade occurred in 2613 patients (91%). The most common treatment-related grade ≥3 AEs included hyper- tension (15%), hand-foot reaction (14%), fatigue (13%), and diarrhea and hypophosphatemia, which occurred equally in 5% of patients. Treatment-emergent hepatic and hematologic laboratory values (irrespective of relation to study drug) of grades ≥3 included increased bilirubin (13%), increased aspartate aminotransferase (AST; 7%), increased alanine aminotransferase (ALT; 6%), anemia (4%), thrombocytopenia (2%), and neutropenia (1%).

“We need to establish clear guidelines on the management of adverse events to make taking the drug more tolerable for patients,” commented Van Cutsem. “These findings add to our knowledge of how to select patients and how to manage toxicities. The large number of patients makes this a rich dataset that will be important for future evaluations.”

Lung Cancer

Preemptive Tetracycline Reduces Incidence and Severity of Afatinib-Triggered Skin Toxicities

Lauren M. Green

Acneiform rash is among the most common adverse effects of treatment with afatinib, but research has found that preemptive tetracycline reduced both the incidence and severity of afatinib-associated rash in 60% of patients, and the antibiotic was well tolerated (Lung Cancer. 2015;88(3):282-288).

Afatinib was approved by the FDA in 2013 as a frontline oral treatment for patients with metastatic non—small cell lung cancer whose tumors harbor EGFR mutations. The targeted agent also is currently under consideration by the FDA for use in the squamous setting.

Researchers from the Instituto Nacional de Cancerologia and Universidad Nacional Autonoma de Mexico in Mexico City examined the use of preemptive tetracycline as a way to control drug-induced skin toxicities in patients receiving afatinib. Prior studies established the effectiveness of tetracycline in treating skin toxicities as a result of the medication’s antibiotic, anti-inflammatory, and immunomodulatory properties; however, no studies had previously evaluated the prophylactic efficacy of tetracycline specific to afatinib-associated skin toxicities.

Patients diagnosed with stage IIIB or IV lung cancer who were being treated with 40-mg afatinib daily were evenly randomized to receive general dermatologic recommendations (n = 54) or 250 mg of tetracycline every 12 hours over 4 weeks, as well as general dermatologic recommendations. The general dermatologic recommendations for both the control group and experimental arm included advice to take brief lukewarm baths, use sunscreen with >30 SPF every 4 hours when outside, and use emollients and hypoallergenic soap.

An independent dermatologist performed baseline and follow-up assessments at weeks 2 and 4 and graded adverse effects and skin color using the Common Terminology Criteria for Adverse Events v4.0 and Fitzpatrick phototyping scales. The patients’ face, trunk, nails, and hair were also photographed and documented.

Researchers found rash to be the most common acute skin toxicity, affecting 65.6% of all participants. Mucositis affected 41.1%, and paronychia affected 33.3% of study participants. Other reported skin toxicities included curly hair (25.6%, skin fissures (24.4%), folliculitis (24.4%), and trichomegaly (22.2%).

Rash incidence was lower in the preemptive group (55.5%) than in the control group (75.5%). Rashes grade ≥2 were 35.6% compared with 15.6% in the control and preemptive groups, respectively. Importantly, “none of the patients developed toxicities secondary to tetracycline, because we used a relatively low dose,” the re- searchers reported. Preemptive tetracycline also reduced the frequency of paronychia in the experimental group compared with controls (37.8% vs 28.9%, respectively) and reduced folliculitis more (28.9% vs 20%); however, neither finding reached statistical significance. The investigators also reported no differences between the control and experimental groups when evaluating patients for xerosis, skin fissures, and mucositis.

Most patients receiving afatinib develop the maximum rash intensity between weeks 1 and 4, suggesting that the “moment when patients start receiving tetracycline plays an important role in skin toxicities,” the researchers noted. They added that preemptive tetracycline treatment is also a cost-effective measure for treating skin toxicities associated with EGFR inhibitors.

Breast Cancer

Lidocaine May Ease Dyspareunia in Breast Cancer Survivors

Lauren M. Green

Researchers at Oregon Health & Science University (OHSU) in Portland found that breast cancer survivors who experience pain during sexual intercourse may achieve comfort when liquid lidocaine is applied strategically to prevent pain.

Findings of their randomized, controlled, double-blind trial were reported online in the Journal of Clinical Oncology.

Low-estrogen therapies associated with breast cancer treatment can make survivors particularly prone to dyspareunia, and the goal of this research was to see if a topical analgesic might help.

“The physical and psychological consequences for the more than 2.8 million breast cancer survivors in the US are very real and often misunderstood or not treated,” noted the study’s lead author, Martha F. Goetsch, adjunct assistant professor in the OHSU Department of Obstetrics and Gynecology, in a statement.

For their study, Goetsch and her team asked 46 estrogen-deficient breast cancer survivors with severe dyspareunia to apply 1 of 2 treatments during the 1-month blinded phase. They used either saline or 4% liquid lidocaine—both clear, odorless liquids&mdash;and applied it to the vulvar vestibule for 3 minutes before sexual intercourse. Each group also received a silicone lubricant.

The study’s primary outcome was patient-reported ratings of penetration pain on a scale of 0-10. Sexual distress, sexual function, and resumption of intercourse were secondary study outcomes.

At the outset of the study, participants reported a median baseline dyspareunia-related pain score of 8. Women who used lidocaine and a silicone-based lubricant had a much lower median pain level (1.0) compared with those who used saline and a silicone lubricant, whose median pain score was 5.3.

When the study was unblinded, 37 of 41 participants (90%) reported comfortable penetration after 2 months of open-label lidocaine use, when initially half of the women had found such intimacy too painful to try. Sexual distress also decreased and sexual function improved in all areas (eg, desire, arousal, enjoyment) with the exception of orgasm, whereas at baseline, most participants had reported abnormal sexual function scores.

Additionally, 17 of 20 women completing the study who had reported abstaining from intercourse had resumed it following treatment, and no partners reported penile numbness.

“This noninvasive treatment will offer distinct help in alleviating the physical—and quite frank- ly the emotional&mdash;pain associated with sexual intercourse, making sexual function more enjoy- able and fulfilling for them and their partner,” Goetsch said.

“As gynecologists, we should be doing everything we can to help breast cancer survivors improve their quality of life through medical treatments that can alleviate pain and suffering,” said Aaron B. Caughey, professor and chair of the OHSU Department of Obstetrics and Gynecology, and associate dean for Women’s Health Research and Policy in the OHSU School of Medicine, in a press statement.

“We need more research on the consequences of breast cancer on women’s health because there simply isn’t a lot of research focusing on this issue.”


Goetsch MF, Lim JY, Caughey AB. A practical solution for dyspareunia in breast cancer survivors: a randomized controlled trial [published online July 27, 2015]. J Clin Oncol.

Nurse Perspective


Ingalls Memorial Hospital Cancer Care Center Harvey, IL

This was a “proof of concept” study designed to determine if a topical anesthetic applied to the vulvar vestibule prior to penetration during intercourse could prevent dyspareunia in postmenopausal breast cancer survivors.

Menopause induces changes in the lining of vulvovaginal tissues causing atrophy and a rise in the vaginal pH, resulting in dryness and less flexibility of these tissues. Postmenopausal dyspareunia has been attributed to vaginal atrophy and decreased lubrication associated with declining estrogen levels. Therefore, treatments have been directed toward treating tissue changes in the vagina and have included interventions such as the use of lubricants, moisturizers, psychoeducational, and physical therapy interventions with limited success.

The aim of this study, however, was directed toward treating pain in the vulvar vestibule rather than treating the vagina mucosal atrophy. In fact, although vaginal pH, cell maturation indices, and atrophy did not change with the use of lidocaine and lubricant over a 3-month period, 90% of the women reported comfortable penetration after 2 months of open-label lidocaine use. This study had several limitations, including that it was of small size with 46 patients enrolled. The participants were primarily white and well-educated, which may limit generalizability to other patient populations.

Some important takeaways from this study include that it represents a possible new treatment option for patients experiencing this very distressing consequence of menopause and treatment-associated menopause, particularly if other standard treatment options have failed; however, detailed, quality instruction is very important in achieving patient compliance. Another important aspect emphasized that sexual dysfunction is frequently not evaluated and not addressed by healthcare professionals, despite the fact that it is cited as one of the top issues affecting patient quality of life. It should be standard practice to screen for and treat these issues. There are a number of tools available to evaluate sexual dysfunction, and the reader is referred to the reference below for an overview and discussion of these tools and their uses.


Dow J, Kennedy SL. Breast cancer survivors and sexuality: a review of the literature concerning sexual functioning, assessment tools, and evidence-based interventions. Clin J Oncol Nurs. 2015;19(4):456-461.

Breast Cancer

Music Before Breast Surgery May Relieve Patient Anxiety

Kelly Johnson

Listening to music before undergoing ambulatory surgery for the diagnosis or treatment of breast cancer lessens patients’ anxiety levels, according to a new study published in the Journal of Clinical Oncology.

A group of researchers, led by Jaclyn Bradley Palmer, MT-BC, music therapist at University Hospitals (UH) Seidman Cancer Center, in Cleveland, Ohio, randomly divided 207 women who were scheduled for breast biopsy into three groups. The first group listened to preferred live music prior to surgery (n = 69), one listened to preferred recorded music (n = 70), and one received usual care and no music before the procedure (n = 68).

“We discovered that anxiety levels dropped significantly from pretest to posttest in patients who heard one preferred song of either live or recorded music before surgery,” Bradley Palmer said in a statement. “In this trial, both live and recorded preoperative music therapy interventions reduced anxiety significantly more than usual preoperative management by 28 and 27 points, representing percent reductions of 43% and 41%, respectively.”

For the study, a registered nurse research assistant administered a pretest to obtain a baseline reading of each participant’s anxiety level. For the live music group, each patient listened to a preferred song performed vocally with guitar or keyboard accompaniment by the music therapist at her bedside. Patients in the recorded music group listened to their recorded preferred song through headphones while the music therapist stood outside the room.

The music therapist held a 5-minute therapy session, which included the preferred song and a brief conversation about the song choice and surrounding emotions.

The usual care group received customary preoperative care for 5 minutes without music and did not have contact with the music therapist.

Posttest data were collected from each patient by the registered nurse research assistant following the preoperative experimental or control condition. Compared with the usual care group, the live- and recorded-music groups had greater reductions, but “there wasn’t a significant difference in anxiety between live music and recorded music,” said Bradley Palmer. “It seems like music, no matter how it is delivered, had a similar effect on reducing a patient’s preoperative anxiety.”

In addition to measuring anxiety levels, the researchers also looked at the amount of propofol needed for sedation, recovery time, and patient satisfaction but found that the results in the live- and recorded-music groups did not differ significantly from those in the usual care group.

“We know that music touches parts of our brain: the emotional center that creates release of our body’s natural opiates, for example, endorphins, enkephalins, and serotonin,” Deforia Lane, PhD, director of Art and Music Therapy at UH Seidman Cancer Center and one of the coauthors of the study, said in a statement. “All of those things that are released, are triggered by auditory stimulation, and music is prime in that ... and it’s without using any pharmacologic intervention—it is simply using the music as medicine.”

The researchers concluded that music therapy has the ability to manage preoperative anxiety in an effective, safe, time-efficient, and enjoyable way. “Anxiety often results when an actual event conflicts with what was anticipated, thus activating the sympathetic branch of the autonomic nervous system,” the authors noted.

“Conversely, because it delivers what is expected, preferred music may stimulate the relaxation response through activation of the parasympathetic branch of the autonomic nervous system. Familiar melodies, rhythmic patterns, and song lyrics may provide a welcome contrast to distress by delivering the predictable in an unpredictable environment, thus restoring balance to the autonomic nervous system.”


Bradley Palmer J, Lane D, Mayo D, et al. Effects of music therapy on anesthesia requirements and anxiety in women undergoing ambulatory breast surgery for cancer diagnosis and treatment: a randomized controlled trial [published online August 17, 2015].

Nurse Perspective

Deirdre Kiely, MS, MPA, RN, ANP

Nurse Practitioner Perlmutter Cancer Center NYU Langone Medical Center New York, NY

There has been a growing interest in the use of complementary modalities such as music therapy as an approach to care together with conventional medicine. This study set out to measure the impact of music therapy on anxiety levels prior to ambulatory breast surgery. The data included measureable physiologic responses to the intervention in addition to anxiety level as self-reported by the patient. The researchers attribute reduced anxiety levels to both the auditory stimulation of the emotional center of the brain as well as providing something familiar (music) in an unfamiliar environment. The intervention also provided a mental distraction prior to surgery, although the time interval between contact with the music therapist and surgery was unclear.

These data do support the premise that patients with a high baseline anxiety level will get the greatest benefit from this intervention. In implementing such a program, it would be best to target those patients who will get greatest therapeutic benefit. The challenge is to recognize which patients are likely to seek out complementary health approaches (CHA) and to encourage them toward safe evidence-based interventions. In discussing the use of CHA with patients, the nurse can help to maximize benefits, minimize risk, and facilitate integration of safe and effective CHA use into conventional care. A music therapy program in ambulatory surgery provides a low-cost simple intervention that may be effective for selected patients.

Some other considerations in addressing the issue of patient anxiety when facing surgery include patient past experience and preparation for surgery. There is a growing body of research that addresses the quality of medical information provided to patients. Patients often report adequate information provision as an unmet need during their care experience. This would suggest that preoperative patient education that addresses the patient’s information needs will result in greater patient satisfaction with the overall surgical experience. A well-informed patient who is provided care in a knowledgeable, supportive environment will potentially have less anxiety associated with surgery.

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