From the Editor: Educate, Communicate, Coordinate

March 14, 2008

As oncology nurses, we know that effective communication, comprehensive patient education, and ongoing identification of patients' needs are key components of excellent patient care.

As oncology nurses, we know that effective communication, comprehensive patient education, and ongoing identifi cation of patients' needs are key components of excellent patient care. The articles in this issue of ONCOLOGY Nurse Edition highlight the extensive nursing expertise required to deliver high-level, comprehensive care in a cancer-management era characterized by new diagnostic tools, new novel therapies, and a greater focus on symptom management throughout the care trajectory. They also underscore how important it is to initiate and maintain open and honest dialogue between clinicians, patients, and families.

 

In the first article of a four-part series on palliative care, Betty Ferrell and Rose Virani outline a roadmap for integrating palliative care into all phases of the disease, from diagnosis through treatment to end-of-life care. They focus on clinical practice guidelines developed through collaboration of four national palliative care organizations known collectively as the National Consensus Project for Quality Palliative Care, and on the preferred practices defined by another important national initiative, the National Quality Forum. The authors also cite keystone educational projects such as the End of Life Nursing Education Consortium (ELNEC), which aims to improve palliative care by comprehensive module-based education of nurse leaders who then disseminate the information at their institutions.

 

The three remaining articles in ONCOLOGY Nurse Edition's special palliative care series will focus on the newly diagnosed patient, the patient with chronic disease, and end-of-life care. The emphasis on the whole patient in palliative care is evident, as physical care is balanced with psychosocial, spiritual/ religious, cultural, and ethical concerns.

 

Indeed, because psychosocial needs and quality of life (QoL) are now key to our concept of quality cancer care, efforts to elicit QoL information have improved. In a special report, Kathy Heptinstall, Operating Director of the Myelodysplastic Syndromes Foundation, Inc., shares QoL fi ndings from more than two dozen clinical nurse specialist–led patient and caregiver forums in the US and Europe. Through open dialogue and questionnaires, the researchers' goal was to explore patients' understanding and attitudes about their MDS, their perceptions of support and understanding from their health care providers regarding their disease, and the impact they believe MDS has had on QoL domains in their daily lives.

 

A common side effect with a significant negative impact on QoL (and care) is oral mucositis, with its associated pain, increased risk of infection, and nutritional defi cits which can delay appropriate cancer treatment.

 

In "5-Minute Inservice," Megan Dunne shares a protocol for evidence-based management of oral mucositis that was developed by a multidisciplinary team including inpatient and ambulatory care nurses; a nutritionist, a dentist, and a pharmacist; and physicians, who reviewed the protocol.

 

Key goals of the evidence-based protocol are consistent oral mucositis assessment and management, including topical anesthetics and opioids, and patient education about helpful dietary and behavioral modifi cations and oral cavity care. Among the fi ndings yielded by an extensive review of the medical literature is that a variety of antimucositis mixtures commonly referred to as "magic mouthwash" have no apparent benefi t. Another oral complication of chemotherapy, particularly with intravenous bisphosphonates, is osteonecrosis of the jaw (ONJ), which can present months before clinical confirmation with vague symptoms such as jaw numbness, heaviness, or reduced sensitivity (eg, to touch).

 

In their excellent case report on ONJ precipitated by a dental extraction in a patient receiving IV zoledronic acid (Zometa) for metastatic breast cancer, Margaret Reilly and Susan Moore emphasize that the key goal is prevention of ONJ through meticulous oral hygiene and regular dental examinations, noting that oncology professionals (and dentists) should be educated about specific ONJ risk factors and prevention strategies.

 

In the increasingly complex world of cancer therapy, the oncology nurse must weigh and consider not only possible consequences of no treatment, as in watchful waiting in the prostate cancer patient, but also the implications of chemotherapy and radiation therapy in terms of future chronic or late effects.

 

Maureen O'Rourke outlines the practical and psychosocial challenges of expectant management (EM) in a patient with early, goodprognosis prostate cancer, suggesting coping strategies that nurses can share with patients and stressing that EM encompasses active disease monitoring, with treatment when the patient's cancer progresses or symptoms develop.

 

Late toxicities after cancer treatment is completed, particularly cardiovascular effects, can be psychologically diffi cult and medically serious for patients, as Dawn Camp-Sorrell relates in her Late Effects Clinic report on cardiomyopathy that developed in a 36-year-old man who had been treated for Hodgkin's disease with an anthracycline and mantle radiation in his mid 20s. Noting the cardiovascular risks posed by radiation therapy, by anthracyclines, and by several other chemotherapeutic agents, she outlines signs and symptoms suggestive of post-treatment cardiovascular toxicity, and advises nurses on appropriate monitoring, interventions, and education.

 

While the past few years have been marked by great strides in novel biologic therapies, promising developments have occurred in cytotoxic therapy as well; in her regular Drug Essentials column, Gail Wilkes shares important information about the epothilones, a new class of agents that cause tubulin polymerization and stabilization similar to paclitaxel and offer a new treatment option for paclitaxel-resistant patients. The agent ixabepilone (Ixempra) was approved in mid October 2007, in combination with capecitabine (Xeloda) in patients with metastatic or locally advanced breast cancer resistant to anthracycline and taxane therapy in whom further anthracycline therapy is contraindicated, and as monotherapy in patients with locally advanced or metastatic breast cancer whose tumors are resistant to anthracyclines, taxanes, and capecitabine.

 

Ms. Wilkes cites essential patient education pointers, including contraindication of ixabepilone/ capecitabine in patients with liver dysfunction, and specifi c symptoms during ixabepilone/capecitabine therapy (eg, possible signs of neuropathy or neutropenia) that patients should report.

 

Taken together, the articles in the February issue clearly point to the need for all of us to fully engage with our patients-to listen attentively to what they are saying; to observe them carefully for signs or symptoms; to communicate openly so an ongoing dialogue is possible; and to always reach out with human warmth. This is the dialogue of the senses that will go far toward ensuring the best possible life for our patients, during cancer treatment and beyond.