Clinical Insights: September 2017
CE lesson worth 1 contact hour that is intended for advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients.
Release Date: September 22, 2017Expiration Date: September 22, 2018
This activity is provided free of charge.
STATEMENT OF NEED
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
ACCREDITATION/CREDIT DESIGNATION STATEMENT
Physicians’ Education Resource®, LLC is approved by the California Board of Registered Nursing,Provider #16669 for 0.75 Contact Hours.
DISCLOSURES/RESOLUTION OF COI
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.
METHOD OF PARTICIPATION
- Read the articles in this section in its entirety.
- Go to Go to www.gotoper.com/go/ONN17September.
- Complete and submit the CE posttest and activity evaluation.
- 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®.
CIPN Experienced by Many Patients Years After Treatment
Ninety percent of patients with cancer may experience chemotherapy-induced peripheral neuropathy (CIPN) during treatment, and many will see this adverse effect long after treatment ends.
According to a study published in the Journal of Clinical Oncology, CIPN can affect physical function and quality of life (QOL), and increase the risk of falls, especially in older survivors.1 Researchers from Oregon Health & Science University (OHSU) in Portland examined 512 female cancer survivors—the majority had breast cancer—with an average age of 62.
Nearly half (47%) reported symptoms of CIPN, on average, 6 years after treatment.
“I was somewhat surprised by the proportion of women who still reported neuropathy symptoms so far after finishing treatment, although, on the other hand, we have been observing this in our exercise trials for a number of years already,” said Kerri M. Winters-Stone, PhD, research professor, School of Nursing at OHSU, and lead author on the study. “That was what drove us to look at these data in the first place.”
Researchers relied on self-reporting from women with and without symptoms of CIPN on the following: maximal leg strength, timed chair stand, physical function battery, gait characteristics (speed; step number, rate, and length; base of support), self-reported physical function and disability, and falls in the past year. They were asked if they experienced numbness, tingling, or discomfort in their feet in the past week and were then categorized into one of 2 groups: symptomatic (CIPN-positive) or asymptomatic (CIPN-negative). Those women reporting symptoms were asked if they started during or after chemotherapy. A 4-point scale was used to report severity: 1 = a little bit, 2 = somewhat, 3 = quite a bit, 4 = very much. The main purpose was to identify targets for functional rehabilitation.
Compared with CIPN-negative survivors, CIPN-positive survivors had significantly worse self-report, except for maximal leg strength and base of support during a usual walk. Gait was slower among CIPN-positive, with those women taking significantly more, although slower and shorter, steps than did CIPN-negative patients. CIPN-positive patients reported significantly more disability and 1.8 times the risk of falls compared with their negative counterparts. Increasing symptom severity was linearly associated with worsening function, increasing disability, and higher fall risk (all P <.05). CIPN-positive survivors were signiﬁcantly more likely than CIPN-negative to be closer to their cancer diagnosis, to have been diagnosed with stage II or III cancer, to have been treated for a cancer other than breast cancer, to be obese, to be less physically active, and to have worse comorbidities.
“Women came into our exercise programs so deconditioned, and with so many lingering problems, from treatment that remained unaddressed for years,” Winters-Stone said. “We basically had to act like physical therapists, rather than exercise trainers, because we couldn’t even get women to perform basic exercises correctly due to their physical limitations, like neuropathy, pain, and weakness. CIPN is very limiting on mobility and people also change where and how they move in their environment such that, over time, they are less and less independent for daily functioning.”
Limitations to the study included cross-sectional, self-report, and post-treatment. However, Winters-Stone said that asking patients about their neuropathy symptoms and considering early intervention seems to only offer advantages in terms of preserving patient QOL during and after treatment.
“Too often I’ve heard that patients were ‘never told’ about a symptom or side effect or that they were told things would ‘go away after treatment,’ and that makes them frustrated and angry,” said Winters-Stone. “I worry that this happens because providers think they don’t have solutions to offer patients, but exercise can help manage so many treatment-related problems if prescribed properly and, ideally, under the supervision of a trained exercise specialist who has experience and education working in the oncology setting.”
Understanding Breast Implant—Associated Anaplastic Large Cell Lymphoma
David Leos, RN, MBA, OCN
For patients with breast cancer choosing to undergo reconstructive surgery post mastectomy, the options include either the use of autologous tissue flaps (free or pedicled) or a prosthetic implant—based approach with prior use of tissue expanders (2-stage) or without (1-stage).
The complication/risk profile for the implantbased approach includes infection, hematoma/ seroma, capsular contraction around the implant, pain, changes in breast sensation, implant rupture/ silicone gel leakage, rheumatologic issues, and breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), a little-known but rare association with a form of T-cell (non-Hodgkin) lymphoma.
The first cases of BIA-ALCL were reported in the mid-1990s.1,2 Primary lymphomas of the breast are uncommon; on the rare occasion that BIA-ALCL develops, it occurs as a primary disease in close proximity to the implant. The incidence of this disease is estimated at 0.1 to 0.3 per 100,000 women with breast implants per year.3 BIA-ALCL commonly presents as a late seroma and/or tumor mass, attached to the scar capsule containing malignant cells, an average of 5.8 years after implant placement (range, 0.4-20 years).4
Subclassifications of ALCL include systemic, primary cutaneous, and secondary. Although systemic and secondary cases are frequently aggressive and express anaplastic lymphoma kinase (ALK), BIAALCL tends to have an indolent clinical course and is usually ALK-negative.5 The clinical presentation is largely unilateral and characterized by an accumulation of fluid around the implant, referred to as seroma. This occurs most commonly, if not exclusively,6 in textured surface versions of both saline and silicone implants as opposed to the smooth surface variety. One theory is that the nonsmooth surface of these implants’ outer linings can create a shearing/abrasive effect within the tissue capsule that, over time, can trigger inflammation, which stimulates an immune response that may subsequently transform into a lymphoma. Biomarkers also provide evidence that underlying inflammation is the likely initiator of this disease.7 Cases of BIA-ALCL confined to the capsule area are considered early-stage disease (localized to the capsule/implant/breast) and tend to have an indolent clinical course. Treatment options include surgical removal of the affected implant and the fibrous capsule. Locally advanced disease may require chemotherapy and radiation therapy in addition to surgical excision. There is reason to believe that BIA-ALCL is more similar to primary cutaneous ALCL than to systemic ALCL, which could favor a surgical remedy over the need for chemotherapy or radiation.8
Much remains to be learned about this disease to prevent delay in diagnosis and inappropriate treatment.9 Lack of routine pathology is likely to delay the diagnosis when women with implants seek medical care from plastic surgeons or primary care physicians for swollen breasts that are assumed to be infected.10
GUIDANCE FOR PATIENTS
The FDA recommends that all women with silicone gel breast implants undergo regular MRI scans starting 3 years after implantation10 to check for implant rupture. However, because most insurance policies do not cover such screening, few women follow these guidelines.11 The agency has also issued a series of safety notices pertaining to data collected thus far. The American Society of Plastic Surgeons and the FDA have jointly established the PROFILE registry to facilitate further determination of an association and is thus set up to capture reports of any confirmed cases.
In a recent article, the presence of biofilm associated with the textured variety of implants appears to be associated with the development of BIA-ALCL.12 This high bacterial load produces a significant and linear increase in lymphocyte activation.13 Research by Sahr et al suggests that gram-negative organisms, in particular Ralstonia pickettii, may stimulate T-cell proliferation which then leads to the development of BIA-ALCL.14 Biofilm is familiar to oncology nurses who work with implanted ports. The presence of this protective buildup within the reservoir of the port provides a spawning ground for the bacteria that lead to central line—associated bloodstream infections. Similarly, textured implant surfaces that are meant to stabilize movement offer an anchoring opportunity for bacterial colonization.
The bacteria could be exogenously introduced despite conscientious surgical technique during implantation or could be part of the preexisting microbiome of the breast.
IMPLICATIONS OF BIA-ALCL AND RESOURCES FOR THE ONCOLOGY NURSE
Although this condition can evolve from implant use in both the aesthetic augmentation setting and that of postmastectomy reconstructive breast surgery, its impact is particularly salient to the oncology nurse. In the former setting, implants can be in place for decades. For the latter, the survivorship of patients with early-stage breast cancer, many of whom have opted for implant-based breast reconstruction after mastectomy, often spans well over a decade from diagnosis. In either case, there is sufficient time for this condition, albeit rarely, to manifest itself.
Oncology nurses, being familiar both with lymphomas and the concept of secondary malignancy risks related to ablative chemotherapy and/or radiation treatment, are prepared to consider this admittedly low risk in a proper context. While the pathogenesis of BIA-ALCL is not definitively known at present, discouraging women from undergoing implant surgery is not believed to be warranted. Through awareness, nurses can provide guidance to their patients who’ve survived breast cancer and gone through reconstruction as part of their rehabilitation back to a semblance of their prior norm.
Although not a secondary malignancy in the usual sense, nurses can be prepared to improve awareness of this possibility and the appropriate diagnostic and treatment resources. These include the NCCN guidelines (v2.2017) for initial and pathologic workup, staging, and treatment.15 Fortunately, early-stage disease can be effectively diagnosed via cytology with immunohistochemical and flow cytometry testing for T-cell markers and CD30. Incomplete resection or inadequate local surgical control may subject the patient to recurrence or to the need for adjunctive treatments, such as chemotherapy and radiation therapy, whereas complete resection may be the definitive treatment in the majority of cases.16 A unifying hypothesis to explain this condition is offered by Loch-Wilkenson and colleagues17: the contamination of textured implants, with higher surface area, by bacteria leading to chronic antigen stimulation in genetically susceptible hosts over a prolonged period of time may result in transformation of T cells into BIA-ALCL. 
References available at OncNursingNews.com.
Are Patients With Cancer at A Higher Risk for Drug-Drug and Herb-Drug Interactions?
Patients with cancer often have many medications to manage and track, making it necessary to monitor them to avoid drug-drug interactions (DDIs) that are often associated with serious adverse events. Additionally, herb-drug interactions (HDIs), caused by any herbal supplements reacting with the treatments, can be a concern as there is a high prevalence of complementary, or alternative, medicine use in the cancer population.
To determine the frequency of both DDIs and HDIs among patients being treated with anticancer agents, a questionnaire was given to 149 patients who started a new anticancer therapy, either oral and/or intravenous, by researchers from Hospital San Juan de Dios and University of Costa Rica. Patients completed the questionnaire either on their own or with a caregiver, identifying any OTC drugs, herbal supplements, or other therapies for a chronic condition they were taking at that moment. The questionnaire also collected information on demographics, anticancer drugs being taken, comorbidities, diagnosis, and the intent of each patient’s treatment.
Researchers then used 2 databases, Lexi-Interact software and an online drug interaction tracker, to evaluate potential DDIs/HDIs from the questionnaire responses; these were only counted when they involved an anticancer agent. Potential HDIs were evaluated through a database established by Memorial Sloan Kettering Cancer Center and the Natural Medicines Comprehensive Database.
The majority of concomitant drugs were treatments for blood pressure-lowering agents. Other drugs noted included nonsteroidal anti-inflammatory drugs, proton-pump inhibitors, opioids, antidepressants, and steroids. Eighty-four patients (56.4%) reported using concurrent herbal supplements.
The median number of herbal supplements per patient was 4. There were 36 potentially clinically relevant DDIs identified in 26 patients (17.4%). Of those patients, 4 experienced clinical consequences in the form of grade 3 mucositis, transient grade 2 aspartate aminotransferase and alanine transaminase elevation, international normalized ratio values above therapeutic range, and toxic plasma levels of phenytoin. Among 75 patients (50.3%), there were 122 potential HDIs detected. Each interaction was then assessed by clinical pharmacists to determine whether the interactions were clinically relevant. The clinical pharmacists consulted Medline and Embase to review previous cases of clinical or theoretic interactions. If a DDIs was rated C (monitor therapy), D (consider therapy modifications), or X (avoid combination), it was considered clinically relevant and the prescribing oncologist was notified. HDIs were graded according to the Natural Medicine Comprehensive Database as mild, moderate, severe, or unknown.
Of the DDIs identified in the sample, 23 were rated C, 11 were rated D, and 2 were rated X. Of the HDIs identified, 3 were rated mild, 75 were rated moderate, and 44 were not graded due to a lack of clinical data. A majority of the DDIs were found to be pharmacokinetic in nature, meaning that the concomitant substance altered the absorption, distribution, metabolism, or eliminations of the other drug.
From these results, the researchers determined that potential DDIs were frequent in the sample; however, there was no association found between comorbidities and DDIs. The researchers also suggested a multidisciplinary approach to identify and avoid potentially harmful combinations with anticancer therapy. A high number of patients at risk for HDIs were also identified.
The researchers recommend that a program of medication surveillance, led by clinical pharmacists, in patients with cancer could prevent a relatively high proportion of patients from experience the potentially adverse clinical consequences of DDIs and HDIs. 
Ramos-Esquivel A, Viquez-Jaikel A, Fernandez C. Potential drug-drug and herb-drug interactions in patients with cancer: a prospective study of medication surveillance. J Oncol Pract. 2017;13(7):e613-e622. doi: 10.1200/JOP.2017.020859.
Phyllis McKiernan, MSN, APN, OCN Blood & Marrow Transplant Program John Theurer Cancer Center, Hackensack, NJ
It is is not surprising that the use of herbal supplements by patients receiving cancer care tends to be underreported. Physicians often do not inquire about herbal or dietary supplements when performing a medication review. Patients, too, may not consider supplements or OTC drugs to be medications and therefore omit them from their medicine lists. Herbal supplements are believed to be “natural” to patients and are more appealing than traditional medicines.
In the study by Ramos-Esquivel and colleagues, 56% of patients receiving cancer treatment reported using concomitant herbal supplements; other studies have shown a similar prevalence. Patients with cancer use herbal and dietary supplements to manage such adverse effects (AEs) as anorexia, nausea, sensory peripheral neuropathy, mucositis, diarrhea, fatigue, or alopecia. In addition, patients are prescribed medications by oncologists or other specialists to control AEs and treat comorbidities. The use of multiple medications and herbal supplements put patients at risk for drug-drug interactions (DDIs), potentially interfering with drug efficacy or leading to AEs.
Although many of the interactions found by the researchers simply needed close clinical monitoring, several combinations required modifications in therapy to avoid serious consequence. Programs to reduce the potential for dangerous DDIs are necessary to improve safety for patients. Oncology care providers need to be diligent in tracking medications for patients receiving anti-cancer therapy and should specifically inquire about herbal and OTC medicines, as well as prescribed medications.
Using a medication reconciliation system with each visit can remind providers to review all patient medications, and each member of the care team should have access to view and update as indicated. An integrative medicine consultant may be a beneficial addition to the oncology care team to help patients navigate through the many supplements available and determine if there are any adverse interactions with their current medical regimen. In addition, nonpharmacologic methods can be explored as a way to decrease the use of other medications or supplements, thus reducing the risk of DDI. As recommended by the researchers in this study, having a clinical pharmacist lead a comprehensive medication review program for cancer patients is another strategy to reduce the number of possible DDIs.
As patients continue to use multiple medications and herbal supplements as part of their therapeutic plan, a clinical pharmacist can identify potential interactions, suggest appropriate drug or herbal combinations, and improve safety for patients receiving anti-cancer treatment.
Women With Lower Limb Lymphedema May Benefit From Exercise
Many patients who undergo radical treatment for gynecologic cancer develop lymphedema in their lower limbs, which can cause pain, swelling, and heaviness in their legs. Although there is currently no cure for the condition, previous research has shown that exercise could be therapeutic to these women. Recently, a group of researchers from Keio University Medical School in Nagasaki, Japan, looked into the immediate effects of active exercise with compression therapy (AECT) on lower limb lymphedema (LLL).
The study involved 22 patients, each of whom had either endometrial cancer (45.4%), ovarian cancer (36.4%), or cervical cancer (18.2%) and were being treated at Keio University Hospital. The mean age was 60.9 ± 8.3 years. Lymphedema staging was performed according to the International Society of Lymphology criteria, with stage II in 18 patients (78.3%) and late stage II in 5 patients (21.7%).
The women participated in high-load AECT on a bicycle machine with stretch bandages attached, low-load AECT, and compression-only therapy, where the patients were instructed to sit still for 15 minutes while wearing a compression bandage attached to their limb.
Three interventions were completed by the women, separated by 1-week “washout” periods to help minimize carryover effects.
The study participants did the first intervention, had their immediate effects tested, and then took the week off before testing the next intervention.
The researchers took measurements directly before and immediately after each intervention, observing lower-limb volume, general symptoms (pain and heaviness of the limb, skin stiffness, and muscular strength), and skin symptoms. Pain and heaviness was measured on a scale of 1 to 100, skin stiffness was evaluated by palpation (pinching) done by a physical therapist and then rated from 1 to 4, and the researchers defined strength as “the maximal peak torque, pedaling at a rate of 50 rpm” on the bike machine.
The results were mixed. While skin-related symptoms were similar with each intervention, “Volume decrement differed significantly between all 3 interventions,” the authors wrote, noting that skin stiffness and pitting edema correlated with volume decrement in both the high- and low-load AECT interventions.
Further, the authors explained that they saw significant improvements in patients’ pain scores, from before the intervention to after, for all intervention types.
Ultimately, they concluded, “These results suggest that high-load AECT has marked effects on severe LLL.” Given the successful results of the study, riding on a stationary bike is something that most women with lymphedema should be able to do, the researchers commented. “Concerning the exercise modality, we considered that it was reasonable for patients with lymphedema to perform the exercises,” they said.
Participants can choose an intensity that they are comfortable with and work up from there, and the piece of machinery poses little fall risk—especially compared with a traditional bicycle someone would ride outdoors.
Also, pedaling on a stationary bike activates most lower limb muscles, while not putting too much stress on the knee joints. Lymphedema, which is also common in patients who are being treated for breast cancer, is the result of an accumulation of lymphatic fluid in certain areas of the body, such as the arms or legs, which stems from intense treatment for cancer, such as lymph node resection, radiation, and chemotherapy. All of the women who participated in the study had surgery, and about half of them had chemotherapy, according to the authors, who mentioned that about 20% to 27% of all patients being treated for gynecologic cancer end up developing lymphedema.
LLL can have negative impacts on house work, physical activity, mobility, social activities, and psychological activities. Additionally, it can also lead to financial burdens for people.
Research like this, which points toward the future of possible treatment options for lymphedema, is important because if the condition is not treated, it will progressively become worse and could have a lasting effect on patients engaging in activities of daily living, severely affecting their quality of life.
While the researchers examined the immediate effects of active exercise with compression therapy, they mentioned that future studies of the method in the long term are also warranted.
“We examined the immediate effects of AECT, but long-term effects also need to be evaluated,” the authors wrote. “In addition, exercise modalities for LLL need to be standardized by examining exercise type, intensity, duration, and frequency.”
Fukishma T, Sano Y, et al. Immediate effects of active exercise with compression therapy on lower-limb lymphedema. Supportive Care in Cancer. 2017; 25(8):2603-2610. doi:10.1007/s00520-017-3671-2. Palliative Care
Automatic Palliative Care Consultations for Advanced Cancer Can Increase Value of Cancer Care
A recent study found that the use of standardized criteria, or “triggers”, for palliative care (PC) consultation in patients with advanced cancer is not only associated with an improvement in the quality of oncology care, but also a reduction in downstream healthcare utilization. When the automatic consult was triggered by specific criteria, 30-day readmission rates and use of chemotherapy after discharge declined, whereas hospice referrals and uptake of support services post discharge increased.
“Patients with advanced cancer admitted to an acute care hospital often have short life expectancies and high morbidity,” stated Kerin Adelson, MD. “For these patients, the integration of PC has improved symptom burden, reduced patient and caregiver distress, increased referral to hospice, and improved outcomes.” Adelson is an assistant professor of medical oncology at Yale Cancer Center and deputy chief medical officer for Smilow Cancer Hospital at Yale-New Haven.
For this prospective cohort study conducted from August 2012 to January 2013, inpatients with solid tumors meeting any of the following 4 criteria received an automatic PC consultation (the intervention group):
• Advanced cancer (stage IV solid tumor or stage III lung or pancreatic cancer)
• Prior hospitalization within 30 days
• Hospitalization >7 days
• Any active symptoms, including pain, nausea, vomiting, dyspnea, delirium, and psychological distress.
Six weeks prior to implementing the intervention, the researchers observed the inpatient solid tumor census daily using manual chart review. This preintervention cohort (n = 48) served as the control group, and results were compared with patients (n = 65) during the 12-week intervention period when the PC consultations were mandated.
As part of the preparation for the intervention, oncology teams were assured that the PC practitioners would “act as partners, help with time-consuming family meetings, and not take over primary care of the patient unless all parties agreed.”
Laminated cards were provided to oncology teams listing the 4 criteria for triggering a PC consult, and they were instructed to place an order for the consult in the electronic health record of any patient meeting 1 or more of the criteria.
Overall, 39% of patients in the usual care preintervention group received a PC consultation, whereas 80% of the intervention group had a PC consult after the automatic triggers were implemented. Comparing the preintervention group to the intervention group, readmission rates decreased from 35% to 18%, hospice referrals increased from 14% to 26%, and receipt of chemotherapy after discharge decreased from 44% to 18%. Intensive care unit use also declined, but it was not statistically significant. Length of stay was not affected.
By implementing eligibility criteria for PC consults, the subjective identification was removed and allowed for a more objective assessment of the patient’s and their family’s needs, the researchers noted.
The Centers for Medicare & Medicaid Services recently launched the value-based payment program, the Oncology Care Model, which encourages value-based care through incentives. In 2016, ASCO called for incorporation of PC into oncologic care for all patients with metastatic cancer. This study emphasizes the importance of this charge and reiterates that patients with advanced cancer should receive dedicated PC services, early in their diagnosis, along with their treatment plan. The researchers concluded, “Expansion of this model to other hospitals and health systems should improve the value of cancer care,” and stressed that although “this intervention was highly successful at improving multiple quality measures in hospitalized patients with advanced cancer, integration of PC needs to begin in the ambulatory setting. This will facilitate goals-of-care discussions earlier in the disease process and may have greater impact on the overall care received throughout the disease trajectory.” 
Adelson K, Paris J, Horton JR, et al. Standardized criteria for palliative care consultation on a solid tumor oncology service reduces downstream health care use. J Oncol Pract. 2017;13(5):e431-e440. doi: 10.1200/ JOP.2016.016808.
The results of multiple studies have shown that early integration of palliative care (PC) improves the quality of life of individuals living with advanced cancer by providing expert symptom management and psychosocial support. Patients diagnosed with advanced cancer should be referred to interdisciplinary PC teams early in their course of treatment to ensure the best possible outcomes.
Recent payment reforms in healthcare put forward by the Centers for Medicare & Medicaid Services and credentialing organizations, such as the American College of Surgeons Commission on Cancer, are now requiring that PC be integrated into oncology care as a way to help meet the goals of oncology care reform.
The results of the recent study by Adelson et al demonstrate how harnessing the power of technology can directly improve patient care. As patients are admitted to the acute care setting, standardized evidence-based criteria were utilized to automatically trigger a PC consultation for patients with any of 4 identified criteria, allowing for a more objective assessment of the patient and family’s needs. Results from this small study revealed that 30-day readmission rates and utilization of chemotherapy after discharge dropped and hospice referrals and support services utilization increased post discharge.
Additional research is needed to determine what other patient populations would benefit from this type of intervention, such as individuals diagnosed with a hematologic malignancy and the pediatric oncology population, and if these criteria could be implemented in the ambulatory setting to automatically trigger a referral to the outpatient PC team. I look forward to hearing more about additional research with this intervention and hope that more inpatient and ambulatory cancer programs begin to utilize standardized criteria to ensure that all cancer patients have access to PC.