Tumor Board

Oral mucositis (OM), also referred to as stomatitis, can negatively impact radiation and chemotherapy treatment schedules and add to oncology patients’ emotional and physical distress. About 35% to 40% of patients treated with cytotoxic chemotherapy will develop OM, with higher rates occurring in bone marrow transplant patients.

Cancer-related fatigue is a common side effect during cancer treatment, and research demonstrates that it is a troubling, lingering side effect for many long-term survivors. Long-term cancer survivor fatigue is under-reported, underdiagnosed, and undertreated.[1] Studies suggest that the prevalence of fatigue in breast cancer survivors may be as high as 30%,[2] and that fatigue levels are higher in cancer survivors than in healthy controls,[3] even as long as 5 years after treatment.[1]

Robyn was 63 years old when she was diagnosed with Stage III ovarian cancer. After recovering from a total abdominal hysterectomy and oopherectomy, she traveled to a comprehensive cancer center to consult with a physician specializing in ovarian cancer. She took her entire collection of pathology slides and reports, laboratory and imaging study reports, and the summary of her surgical procedure.

Hypertension (HTN) is prevalent in the general population, particularly in individuals over the age of 60 years. More than 50% of individuals aged 60 to 69 years and more than 75% of individuals age 70 or older are affected.[1]

Bendamustine HCl for injection is FDA approved for treatment of patients with chronic lymphocytic leukemia (CLL) or indolent B-cell non-Hodgkin’s lymphoma (NHL) that has progressed during or within 6 months of treatment with rituximab (Rituxan) or a rituximab-containing regimen.

The patient, “JB,” is a 68-year-old woman who underwent a right lumpectomy and axillary node dissection for stage II breast cancer. Her oncologist suggested adjuvant chemotherapy (four cycles of cyclophosphamide [Cytoxan] at 600 mg/m2 plus doxorubicin [Adriamycin] at 60 mg/m2) followed by local radiation therapy.

When caring for patients with a new cancer diagnosis, oncology nurses generally have clear and distinct plans to assist each patient through the phases of diagnosis and treatment. Nurses provide guidance, support, and well-defined patient education regarding the planned treatment, as well as anticipatory guidance regarding management of side effects and emotional responses to diagnosis and treatment.

One of the potential side effects of chemotherapy is cardiac toxicity. The resulting damage to the heart can range from non–life-threatening events to devastating heart failure. The spectrum of these events can occur almost immediately, during a drug infusion, or as a delayed complication later in the patient’s life. Oncology nurses not only need to be familiar with identifying and intervening in acute cardiac events, but also in some instances will need to monitor for delayed cardiac toxicities during the continuum of the patient’s life.

Hospice care continues to be underutilized. Indeed, owing to untimely referrals, many patients who begin hospice care unfortunately die shortly thereafter, having never received the full benefits provided by hospice. In her excellent article, Dr. Prince-Paul provides a case example that demonstrates the familiar multifaceted issues faced by cancer patients nearing end of life and discusses how hospice care could be of tremendous benefit to the patient, family, and professional.

Change is in the air-and I don’t just mean the arrival of spring. The current national focus on health care is clearly evident from many quarters, including policy makers, health care institutions, and clinical staff. In addition to the discussion on health care coverage, there is an increasing emphasis on patient-centered care. As a result, we have before us a unique opportunity to assure the inclusion of survivorship and end-of-life care as formal parts of the health care continuum.

The patient, "JD," is a 62-year-old Caucasian female who had stage IV non–small cell lung cancer (NSCLC) diagnosed 3 months ago. Her medical history is significant for chronic obstructive pulmonary disease (COPD). She quit smoking cigarettes more than 6 months ago after having smoked a pack per day for 40 years.

The cytochrome P450 microenzyme system has been an important protective system for living things for at least 3 billion years. It is a group or superfamily of isoenzymes that live in the endoplasmic reticulum and mitochondrial membrane of cells, and initially were responsible for detoxifying any poisons that were inhaled or ingested. As a result, these enzymes are found in the nose, saliva, kidneys, and lungs, and in greater numbers in the small intestines and liver. Cytochrome P450s account for about 75% of total metabolism and are important in oxidative metabolism-chemical modification/degradation of drugs.

In their informative article, Richard O’Hara and Diane Blum touch on several key challenges of cancer survivorship. Looking at cancer through the lens of social concerns and developmental issues, they have brought important psychosocial aspects of survivorship to the forefront of our attention, with a particular focus on the domain of social well-being within the parameters of interpersonal relationships, and financial, employment, insurance, and legal issues.

When my doctor told me that I would have to put my life on hold at age 25 because tests confirmed that I had Hodgkin’s disease-cancer!-my life changed totally. I had to quit my job, move back in with my parents, and wonder about the quantity and quality of the rest of my life.

It is estimated that more than 62,000 men and women will be diagnosed with melanoma in 2008, with more than 8,400 deaths, and an estimated lifetime risk predicted to be 1 in 55.[1] Although deadly in its later stages, melanoma carries an excellent prognosis if it is diagnosed early. Fortunately, most melanoma cases (80%) are diagnosed at a localized stage; the 5-year survival rate for this group is 98.5%.

Bill, 53 years old and a 3-year survivor of non-Hodgkin’s lymphoma, reflects on his ongoing journey as a cancer survivor: “I was very sick and treatment was very rough, complete with a severe allergic reaction that was difficult to diagnose for a long time. But I made it through to the other shore…remission. Since then, I’ve been trying to rebuild a new life…Living with an 18-year-old [son], I can see how in some ways I’m in a parallel universe…Both of us are looking out at the world before us, at all the many possible options...trying to figure out what we want tomorrow to look like.

As difficult as treatments are for many cancer patients, another difficult time awaits them at the conclusion of therapy. Until that point, patients have become accustomed to the fleeting comfort of regularly scheduled appointments for diagnostic testing, chemotherapy and/or radiation treatments, and ongoing contact with health care professionals. Conclusion of treatment can seem abrupt and the absence of attention can be unsettling for many. It is at this point that patients often ask, “What can I do now to help myself?”

In 2008, roughly 1.44 million Americans were diagnosed with cancer,[1] and accordingly were labeled as “cancer survivors.” Fortunately, for roughly 65% of those who were newly diagnosed, this label will expand to encompass issues of long-term survivorship and health maintenance.[2] Extended cancer survivorship is a relatively new concept. In the past, most people who were diagnosed with the disease did not survive it. While longer survival times are a measure of success, the dark side of this victory is that a substantial proportion of these survivors will experience recurrence or second cancers. In addition, many more will go on to develop comorbid conditions such as cardiovascular disease (CVD), diabetes, or osteoporosis, which often kill or debilitate survivors at much higher rates than the cancer itself.[3,4]

Osteoporosis, the most common late effect of cancer treatment in the US, occurs with greater frequency among cancer survivors than the general population. Survivors of breast cancer, prostate cancer, and childhood leukemia are at particularly high risk for changes in bone mineral density (BMD) / osteoporosis that can lead to fractures.[1] In breast and prostate cancer patients, bone effects are often the result of endocrine therapy–induced alterations in bone microarchitecture. They also can be caused by other types of cancer therapy, vitamin D deficiency, and other physiological changes that may or may not be related to cancer or its treatment. In childhood leukemia patients, bone effects can be caused by a variety of factors, including corticosteroid therapy, radiation therapy to the brain, and the disease itself.

When you have cancer, you can get diarrhea for a number of reasons. Most often, it is a side effect of treatments, such as chemotherapy or radiation therapy.

Cancer occurs in approximately 1 per 1,000 pregnancies. For the woman and her family, the diagnosis creates an emotional upheaval of hopes and fears and raises the issue of immortality and mortality simultaneously. The treatment proposed to save the mother can appear in direct conflict with the desire to protect the developing fetus.

A diagnosis of cancer and its subsequent treatment can be a very frightening and confusing experience for the pregnant patient, and are challenging for the physician and nurse. As women delay childbirth until later in life, the incidence of pregnancy associated with cancer is expected to increase. Currently, approximately 1 in 1,000 pregnancies is complicated by cancer.[1–5]

When you have cancer, constipation is more likely to occur because of the cancer itself or as a side effect of treatment. If you have constipation, your doctor or nurse can help you to treat it and prevent it in the future.

42-year-old Caucasian female who was in her usual state of health when her first mammogram showed suspicious calcifications and a spiculated mass in the upper outer quadrant of the right breast. An ultrasound-guided biopsy showed an invasive ductal carcinoma. She underwent a lumpectomy, with the excised tumor measuring 1.2 cm. The tumor was estrogen and progesterone positive and HER2/neu negative.

Gina, age 9, and Rosemary, age 66. They had different cancers, but developed similar skin ulcers over their entire bodies. Gina's wounds were open to air for 4 weeks. Her pain was severe. Two weeks after starting wound care, Gina allowed us to take pictures of her wounds. We promised to teach doctors and nurses how to care for her wounds. Unfortunately, Gina died. The pictures were lost. A year later, Rosemary was admitted with a similar skin condition and allowed us to photograph the progression of her wound care. Our promise to Gina is now kept. Here we describe the wound care plan necessary to relieve the pain and discomfort of partial-thickness wounds from dermatological conditions in oncology patients.

With perhaps 100 patients scheduled for chemotherapy each day and about the same number of consultations, the nurses, physicians, and staff in any medium-sized oncology clinic are fully booked. Changing their routines may be the last thing anyone wants to think about.

Diabetes mellitus is a frequent comorbidity of cancer patients. The growing epidemic of diabetes is anticipated to have tremendous impact on health care. Diabetes may negatively impact both cancer risk and outcomes of treatment. Oncology nurses are ideally positioned to identify patients at risk for complications that arise from cancer treatment in the setting of pre-existing diabetes. Additionally, oncology nurses may be the first to identify underlying hyperglycemia/hidden diabetes in a patient undergoing cancer treatment. Strategies for assessment and treatment will be discussed, along with specific strategies for managing hyperglycemia, potential renal toxicity, and peripheral neuropathy. Guidelines for aggressive treatment of hyperglycemia to minimize risks of complications will be reviewed. The role of interdisciplinary care, utilizing current evidence, is crucial to supporting patients and their families as they manage the challenges of facing two life-limiting diseases. Whole-person assessment and individualized treatment plans are key to maximizing quality of life for patients with cancer and diabetes.

FDA-Approved Drugs: 5-HT3 receptor antagonists Zofran (ondansetron), Kytril (granisetron), Anzamet (dolasetron), Aloxi (palonosetron); NK-1 receptor antagonist: Aprepitant (Emend)

Cancer clinical trials are a necessary component of the effort to improve cancer prevention, diagnosis, and treatment. Essential to this process is the informed consent of the individuals who participate in these research studies. The purpose of this article is to describe patient, provider, and informed consent process issues with presentations of data reported in the current literature. The role of nursing in the facilitation of informed consent is discussed.

Bisphosphonates are an important part of managing bony metastasis of prostate, breast, lung, and other cancers but can cause osteonecrosis of the jaw (ONJ) in some patients.

Nursing management of patients with advanced malignancies presents a formidable challenge. In addition to the discomfort and debilitation these diseases can cause, side effects of traditional treatment modalities such as surgery, chemotherapy, and radiation may lead to severe and sometimes fatal sequelae. New targeted therapies promise an effective treatment with more easily tolerated and managed side effects. Basic understanding of the drugs' mechanism of action contributes to the successful management of the toxicities that can be manifested. Effective patient education results in improved compliance with treatment regimens and potentially improved clinical outcomes. Nursing intervention remains a vital component in the successful use of these novel agents.

The high prevalence of pain in the cancer population underscores why pain management is integral to comprehensive cancer care. How well pain is controlled can have a profound effect on the cancer experience for both patient and family. The goals of pain assessment are to prevent pain if possible, and to identify pain immediately should it occur. This can be facilitated by standardized screening of all cancer patients for pain, on a routine basis, across care settings. A comprehensive assessment of pain follows if a patient reports pain that is not being adequately managed. Oncology nurses play a huge role in pain assessment and management throughout the course of a patient's disease. A basic understanding of the types of pain seen in the cancer population as well as inferred neurophysiologic pain mechanisms and temporal patterns of pain can help focus the pain assessment. This in turn will lead to targeted pain management strategies

Chemotherapy-induced febrile neutropenia (FN) predisposes patients to life-threatening infections and typically requires hospitalization. The goal was to investigate whether a risk assessment tool aligned with national guidelines could help identify patients at risk of FN and reduce FN-related hospitalizations. Beginning in October 2004, oncology nurses applied the new risk assessment tool to all patients initiating chemotherapy or a new regimen. Patients at risk for FN received prophylactic colony-stimulating factor. Charts for 189 patients receiving chemotherapy in fiscal year 2005 (FY05) were compared with charts of 155 patients receiving chemotherapy in FY04, before the tool was implemented. The incidence of FN-related hospitalization declined by 78%, from 9.7% in FY04 to 2.1% in FY05 (P = .003). Total hospital days decreased from 117 to 24. Routine systematic evaluation by oncology nurses improves recognition of patients at risk of FN and substantially reduces FN-related hospitalization.

Major deficiencies in the management of cancer-related pain are well documented and impact all dimensions of the patient's life, including physical, psychological, social, and spiritual well-being.

With the trend toward the use of oral rather than intravenous therapies for cancer, nonadherence to treatment has become an increasing concern. Advanced practice nurses are in a good position to assess and monitor adherence to oral endocrine therapies. Research on adherence has been limited; to date there are no specific published guidelines for ensuring adherence to endocrine regimens. However, studies have identified many factors that may lead to nonadherence, including demographic, social, and psychological characteristics of the patient; characteristics of the disease and the treatment regimen; and the nature and quality of the patient/clinician relationship. These factors provide a framework that advanced practice nurses can use to identify potential problems and to work collaboratively with patients.

Dr. Ann Berger does an excellent job of writing to the chronic pain sufferer in her book Healing Pain. Health-care providers and family caregivers will also find it an excellent resource and can benefit greatly from reading this work. Throughout the book the author maintains a true sense of hope for the individual experiencing significant pain. Her ability to communicate this sense of hope will be rather contagious for the health-care provider who may have become less than enamored with our ability to accomplish pain management in individuals with complex pain syndromes.

Oncology nurses play a pivotal role in educating the cancer patient who is about to commence oral chemotherapy. Increasing numbers of patients are receiving oral chemotherapy at home, and with this move to oral self-