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Chapter Summer Newsletter 2014



Providing optimal care through promotion of professional standard, networking and development




Kirsten D’Angelo, RN, BSN, CCRP


Wouldn’t it be great if we could detect the presence of cancer  using a blood or urine sample? Or discover tumor sensitivity to chemotherapy by testing a saliva sample? The possibilities are endless, and biobanking may be the key to opening these frontiers.


The idea of collecting specimens for genetic testing and experimentation may seem like a relatively new concept. Yet, this kind of research has been going on for a very long time. The

Aboriginal genome, for instance, was sequenced from a lock of hair originally given to British ethnologist Alfred Cort Haddon in the 1920s. Haddon gathered samples from all over the world that are now housed at the University of Cambridge, UK. The over 74,000 studies done on the famous HeLa cells have brought to light many discoveries; including cell biology, vaccines and cancer. This kind of discovery is happening at a very rapid pace and the result will be more personalized medicine in the future.


Personalized medicine is treating the person as an individual for their specific conditions. The reason

some patients respond better than

These types of studies could not be conducted without the patients that voluntarily offer their specimens and medical history for research. It is thought that approximately 95% of patients consent to donation of their specimens for future research. This may be due to a genuine desire to help others that suffer from a similar condition or disease in the future. Specimen donation is also relatively easy for patients. There is minimal risk with most specimen collections, and

typically there is very little or no follow up required of these patients. It may be seen as an easy way to contribute to the greater good.


Like anything else, biobanking does not come without its challenges. Collecting, processing, storing and maintaining as well as funding can be difficult. Before any of these processes, the patients must also sign an informed consent stating they wish to provide specimens and medical information. Explaining the concept of future research to patients is very important. Patients must know that their specimens could be utilized for unspecified future research, may be stored for an infinite amount of time, their identity will be protected,

they may be contacted for future research, their medical records may

others to treatment is attributed to the unique DNA, RNA and proteins they make. Helping people avoid unnecessary treatments and side effects is just one of the many benefits biomarker research and discovery can provide. Prediction

Metabolomics is the study of the function


be accessed and how access will be gained. If samples may be shared with outside entities, they also need to be informed of the scope of this possibility.


One of the biggest challenges is

of diagnosis, prognosis, treatment response, treatment choice or recurrence can arise from analysis of these biomarkers.


These discoveries can be made on many levels. Genetic, proteomic, and metabolomic research can be done on biological specimens.

Biological specimens are products of the human body; blood, urine, saliva, tissue, cerebrospinal fluid, bone marrow, nasopharyngeal secretions, synovial fluid. These specimens can all tell a story about the individual they are sampled from. Genetics is the science of heredity, dealing with resemblances and differences of related organisms resulting from the interaction of their genes and the environment. The study of the functions, structures, and interactions of proteins is called proteomics. Metabolomics is the study of the function of cells; the study of all the metabolites present in cells, tis- sues, and organs. It is felt by many that biospecimens are critical in medical research; enabling the genomic analysis of cancer, establish- ing validation of basic science discoveries, and helping to determine which patients are responding to treatments via clinical trials.

the development of commercialization of biobanks. With limited funding for research utilizing biospecimens, biorepositories must sustain operations through external funding, including commercialization. Patients need to understand this possibility,



Continuedonfollowing page



What’s Inside...

From the Editor                                                         2

Highlighting a Member                                        3

Meeting Summaries                                                    3

From the President                                                 6

Officers and Staff                                                8

From the Editor



In the April Issue of the Clinical Journal of Oncology Nursing, Linda Sarna, the editor of the journal, talks about the 2014 Surgeon General report, The Health Consequences of Smoking- 50 Years

of Progress. (http://www.surgeongeneral.gov/library/  reports/50-years-of-progress/). In her article, Sarna speaks about the statistics related to smoking and how nurses measure up in those statistics. I was surprised to learn that while nurses have cut their rate of smoking by 36%, 7% of nurses continue to smoke and that number is 25% for licensed practical nurses. When the number is compared to our physician counterparts, their rate of smoking is only 2%. (Sarna, 2014)


Sarna speaks about how important it is for health care providers to be non-smokers, not only for our own health but for the health of  our patients. Smokers are less likely to provide interventions for smoking cessation and control to their own patients. In 2003, a website was developed to help address smoking cessation for nurses. The website’s purpose is “… to build capacity among nurses to equip them to assist patients with tobacco dependence and to become more involved in tobacco control efforts. Tobacco Free Nurses

work, nationally and internationally, with nurse champions, nursing and health professional organizations, academic centers and other partners in order to enhance nursing’ involvement in all aspects of tobacco control.” (www.tobaccofreenurses.org).


The delivery of smoking cessation, in my opinion, should be a routine part of cancer nursing care, but according to Sarna it is not even in designated cancer centers. This is despite the evidence that continued smoking causes serious harm to patients.  There is now evidence to support the link between negative health outcomes

and smoking. Additionally smoking has been linked to increased





Biobanking and the Future of Personalized Medicine?

Continuedfrom front page



and with that comes the challenge of the right to withdraw. They must know up front that if their specimens are shared with other entities, those specimens will not be able to be withdrawn.


Another challenge is regarding the moral quandary of a patient’s right to know about discoveries that might be made about their genetics. Are biobanks obligated to disclose information to them? If so, how logistically can this happen after the commercialization of specimens? This is an ongoing debate in the biobank arena, as it is also felt that research is not clinical or diagnostic care, and upholding the confidentiality of the patient’s identity remains of utmost importance.


Whatever your stance on the matter, one thing remains clear. It is our obligation to assure that patients are well informed about whether or not information will be shared with them. It is in the best interest of the patient to remain transparent in all areas of



mortality from cancer. There is emerging evidence, according to Sarna, that continued smoking after diagnosis results in poorer treatment outcomes. (Sarma, 2014).


In light of all of this information, I am so proud of MDONS’s participation with Tarwars, an educational program for fifth grade students on the perils of smoking. This program, run by Susan Wozniak, is an important part of the community outreach provided

through MDONS. I encourage you to take part in this important program. If you are unable to be a participant in the education program, then take part in voting for the best posters.


Many of you who know me, know that I am an avid smoking cessation supporter. So most importantly, if you are one of the 7% of nurses who continue to smoke,

consider quitting. Take advantage of the resources offered to you. If you are not a smoker, remember the role you

play in helping those around you- family, friends, and patients in this difficult task.


State of Michigan




http://www.michigan.gov/mdch/0,1607,7-132-  2940_2955_2973_53244---,00.html





AmericanCancerSociety’sguidetoquittingsmoking http://www.cancer.org/healthy/stayawayfromtobacco/  guidetoquittingsmoking/index?sitearea


CentersforDiseaseControlandPrevention resources http://www.cdc.gov/Tobacco/quit_smoking/how_to_quit/index.  htm





biobanking, letting them decide for themselves if they are willing to share a part of themselves with the world.




Carbary, J.C. (2014, Feb 27). Biobanking & Future Research: Addressing the “Unknown” in the Protocol and Consent. [Webinar]. In Quorum Review Webinar Series. Retrieved from: http://www.quorumreview.com/recording-biobanking-  future-research/?utm_source=Webinar+Registrants+-+FEB+2014&utm_  campaign=7e2fc3c9bd-September_2013_Webinar_Slides&utm_  medium=email&utm_term=0_5aa19772cc-7e2fc3c9bd-767890


Baker, M. (2012, June 7). Biorepositories: Building Better Biobanks. Nature:InternationalWeeklyJournalofScience.Retrieved from: http://  www.nature.com/nature/journal/v486/n7401/full/486141a.html?WT.ec_  id=NATURE-20120607


Jeffers, B.R. (2001). Human Biological Materials in Research: Ethical Issues and the Role of Stewardship in Minimizing Research Risks. AdvNursSci, 24(2): 32-46.


Printz, C. (2014, Apr 15). Banking on the Future: Biobanking Human Blood and Tissue Advances Cancer Research. CancerScope,1131-1132.


Zimmer, C. (2013, Aug 7). A Family Consents to a Medical Gift, 62 Years Later. The New York Times. Retrieved from: http://www.nytimes.com/2013/08/08/  science/after-decades-of-research-henrietta-lacks-family-is-asked-for-consent.  html?pagewanted=all&_r=0

Highlightinga memberHeather Lowry

Permit me to introduce you to our MDONS highlighted nurse, Heather Lowry, your president-elect for 2015. Heather is

proud of her four-year MDONS membership and would encourage all oncology nurses to join the team. She feels strongly that MDONS offers

its members a multitude  of professional growth opportunities and benefits.


Heather’s nursing career spans 19 years, beginning with graduation from University of Michigan School of Nursing in 1995 to her current status as an MSN prepared Nurse

practitioner for the past thirteen years. Before arriving at her current professional destination, Heather practiced in various clinical settings including ER, mother and baby care, OB/GYN and nursing education before assuming her current responsibilities at Beaumont in the Breast Care Center. There she cares for high risk women and men, breast cancer survivors, and patients with benign breast problems.


Each of these roles has served, in its own way, to enhance Heather’s professional knowledge/experience base.


Married (to her husband, John) with children (Fiona – 10 and Elise – 7) (and dog, Lola), Heather enjoys being outdoors, biking,

travelling, and seeing the country with her family. When not working, participating in MDONS activities, or accompanying her daughters

to their sports and school activities, Heather is able to set aside some free time for knitting and her new-found hobby of Nordic Walking.


Heather’s career was positively impacted by two recent significant events: She was nominated earlier this year for

a Nightingale Award, and was honored this month with the MDONS 2014 advanced practice nurse award.

While very proud and pleased to have been lauded professionally with these recognitions, Heather states that her most memorable nursing accomplishments are those where she knows she has truly made a difference in someone’s life. She is truly grateful to be

in a profession “where even something small can make a world of difference for someone who may not be in the best

place with their health”.


In addition to her already impressive list of professional accomplishments, Heather can now add to that list her current interest and involvement in health policy formation. Heather feels that she still has much more work left to do to help change the way health policies are currently enacted and the way health care related laws are passed. Gayle Snider, RN, MSN, OCN





Meeting  Summaries  >>>>>>>>>>>>>>>>>>>>


24th Annual Conference

Susan D. Hansell, RN, BSN, OCN



This year’s conference provided attendees with a wide variety of speakers and topics. Included in the topics were surgical oncology, social media, survivorship, radiation topics and bone marrow transplant.


Richard N. Berri, MD, Director of Surgical Oncology and Peritoneal Malignancies Program at Van Elslander Cancer Center, St. John Hospital and Medical Center, started the conference off with a very interesting talk about cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with GI and  GYN cancers with metastasis to the peritoneal cavity.  In patients with peritoneal cancer indices less than 6, this treatment has shown improvements over systemic chemotherapy alone (median survival (MS) of 40 months versus 20 months).  Candidates are limited by typical surgical criteria and peritoneal cancer scores.


The treatment involves laparoscopic or open surgery with the goal   of removing all known metastasis, followed by heated chemotherapy into the peritoneal cavity for about 90 minutes in the surgical suite. Patients typically suffer fewer side effects of chemotherapy due to isolation to the diseased area; however recovery from abdominal

surgery is no different than other abdominal surgeries.  Post-surgical care is typical with special emphasis on fluid management.


Morris A. Magnan, PhD, RN, Clinical Nurse Specialist Ambulatory Care, Karmanos Cancer Institute presented a lively talk explaining   the professional and legal risks to healthcare professionals with web- based social networking. He encourages us to think about whether use of social media could harm patients, self, employers, and/or your profession.  Nurses must be familiar with their organization’s policies and the ANA Code of Ethics with regard to personal conduct and media. Nurses can also refer to the ANA’s 2011 position, Principles  for Social Networking (www.NursingWorld.org) for additional tips.


Gayle Groshko, RN, BSN, OCN, Nurse Case Manager, Radiation Oncology, William Beaumont Hospital discussed teletherapy (external beam) and brachytherapy. Tissue-sparing treatment trends include using genes and proteins to radiosensitive targets and accelerated partial breast irradiation (APBI) utilizing a surgically implanted balloon to manage irradiation treatments. Ms. Groshko

also covered radiation therapy implications for nurses which focus on management of fatigue and skin issues.


Michelle Manders, RN, BSN, Clinical Nurse in Gamma Knife Radiation Oncology, William Beaumont Hospital explained Gamma Knife is used to treat benign and malignant tumors in the head, movement disorders and trigeminal neuralgia. Gamma Knife is  also being studied to treat Parkinson’s, epilepsy, chronic pain, OCD and depression and chronic migraine headaches. Candidates with less than 10 tumors, KPS scores greater than 70, and well-controlled

underlying disease are offered radio surgery (one high dose), or radio therapy (multiple lower doses). The preparation of the patient with frame placement, imaging and treatment planning (i.e. mapping)



February Continuedfrom previous page

are the most difficult part of the process, with the actual radiation treatment being quick, painless and silent.  The treatment has a delayed effect of 4-6 months, and can be repeated if necessary. Side effects are minimal, and often related to the head frame and post- treatment steroids given.


Linda Vanni, RN, MSN, ACNS-BC, NP, Nurse Practitioner, Pain Management, Providence Hospital, discussed the importance

of treating pain in all patients, including those with histories of substance abuse.  She offered the benefits and risks of using methadone to treat neural and organ pain (low cost, effective, but dosing is critical).  Items to watch for include DEA reclassifications of hydrocodone and marijuana, acetaminophen control, over-the- counter formulations of lidocaine for zoster pain, EtCO2 monitoring with PCA pumps (replacing pulse-ox), and genetic prediction of

chemotherapy-induced peripheral neuropathy (CIPN) and medication effectiveness.


Deborah Olszewski, RN, MSN, AOCN, Hematology-Oncology Nurse Practitioner, Palliative Care, Karmanos Cancer Institute gave a detailed overview of the long-

term effects of cancer therapies,



are now available to combat and prevent pseudomonas and fungal infections. Viral infections continue to be a challenge, and additional work is needed in this area.   As the immune system is not able to fight residual cancer cells post-transplant, the use of maintenance chemotherapy until immune system recovery is being studied to reduce risk of relapse.


Chronic GVHD, in which the patient’s immune system attacks  the skin, GI system (diarrhea), liver, and lungs 4-6 months post- transplant, occurs in 30-80% of allo transplant patients. GVHD progression to constrictive bronchiolitis (often not detectable with chest x-ray) has a 60% morality rate.  Studies are now being conducted with digital radiography (CT) to detect early GVHD

lung involvement and initiate treatments sooner. T-cell reduction using extracorporeal photopheresis treatments can be used to treat GVHD (40% better response over conventional treatment alone). Vitamin D deficiency has been found to be correlated to worsened GVHD symptoms, and treatment with vitamin D is being studied for prevention and treatment.


Prevention of GVHD has been studied using rituximab (not effective),

calcineurin inhibitors (cyclosporin and tacrolimus), mycophenolate

based on results from the St. Jude Lifetime Cohort Study. Major adverse health effects of cancer treatments included pulmonary, cardiac, auditory, endocrine- reproductive, and neurocognitive problems, and subsequent malignancies.  Implementation  of survivorship clinics is


genesandproteinstoradiosensitivetargetsandacceleratedpartialbreastirradiation(APBI)utilizinga surgically implanted balloontomanageirradiationtreatments

and low dose methotrexate.  A recent study showed 50% reduction in GVHD with no change in relapse rates using alemtuzumab or thymoglobulin to ablate T-cells. The trick is to balance the suppression of the immune system to reduce GVHD without increasing the risk of

recommended. The focus of survivorship clinics would be to ensure documentation of all treatments and follow-up care, appropriate screening for early intervention of probable adverse effects, and the treatment of chronic significant side effects of cancer treatment.


In the closing presentation, David Frame, PharmD, Clinical Hematology/Oncology/BMT Specialist, University of Michigan focused on allogeneic (Allo) stem cell transplants, which are used most frequently to treat multiple myeloma (life-extending), NHL, AML, HD, MDS, and aplastic anemia (for cure).  Allo transplants differ from autologous transplants (self) in that the transplanted

cells can be from and HLA matched identical sibling, un-related HLA matched, or HLA mis-matched donor. HLA typing compares 6 major antigens. The risk of graft versus host disease (GVHD) complications increases with increasing mis-match and unrelated donors.


Because the patient’s immune system can take 6 to 8 months to recover with allo transplants, infections are a risk. Better medications

relapse due to immunosuppression.


Veno-occlusive disease, or sinusoidal obstruction syndrome (SOS) is another risk with allo transplant, leading to hepatic failure, renal failure, and death in 80% of patients afflicted. Studies are showing

promise to treat this with defibrotide, and prevent prophylactically in combination with busulfan.


Other complications of allo transplant include osteopenia and osteoporosis (68%), musculoskeletal injuries (35%), and

atherosclerosis. Nurses can help by promoting appropriate screening, recognition of other non-GVHD issues such as eczema, iron overload, hypothyroidism, infections and adrenal insufficiency, and promoting prophylactic treatments like pamidronate and statins (when appropriate).


A giant thank you is extended to all of the talented speakers, exhibitors, and participants at this year’s conference.



Join a Global DiscussiononCancerCare

The MASCC/ISOO 2014 International Symposium will spotlight excellent science and cutting-edge research aimed at enhancing the lives of people with cancer. Head to Miami, FL, June 26–28 for an international perspective on cancer care.



Presented by Larmender A. Davis, MSW, LMSW, OSW-C and Morris A. Magnan, Ph.D., RN

Summarized by Theresa Benacquisto, RN,BSN,OCN



Distress in cancer is defined by the National Comprehensive

Cancer Network (NCCN) as a multifactorial, unpleasant, emotional, experience of a psychological, social, and/or spiritual nature that may interfere with the ability to cope effectively with the disease and its treatment. Some levels of distress is normal. It extends along a continuum, ranging from normal sadness to panic and crisis.


Psychological distress varies by cancer type and stage. One study  by Zabora et al, 2001, reported a range of 29.6% -43.4% in distress prevalence.  Another meta-analysis by Mitchell et al, 2011, reported 30% -40% of patients with

various types of cancer had



cognitive impairment; communication barriers; severe co-morbid illnesses; social problems; and spiritual concerns. Cancers with the highest prevalence of psychological distress are lung; brain; liver; pancreatic; and head/neck.


When creating a screening process, many considerations need to be address. These include who will screen; screening instrument; timing; referral decisions with options; and documentation. The impact of screening tools on recognition of distress is important.

When NO screening tools are used doctors incorrectly determined distress 35% of the time. They also recognized severe distress 36.6% of the time. Providers that include nurses did not acknowledge verbal cues of distress 43% of the time.


Distress tools include the NCCN Distress Thermometer and Problem List; Brief Symptom Inventory (BSI-18); Hospital Anxiety and Depression Scale (HADS); Functional Assessment of Chronic Illness

Therapy (FACIT); Profile of Mood States (POMS); and PSYCH-6.

some combination of mood disorder. There is a wide range of depression and anxiety prevalence noted in studies due to the variety of different measures used and checked at different times.


The history of distress screening includes the first published standards and guidelines for


After a clinician determines high risk patients, referrals can be made to social work, mental health, pastoral care, and the medical team.


There are many risk factors  for suicide in cancer patients. These include: hopelessness; advanced stage of disease; fear

distress management in 1999. The NCCN is a not-for-profit alliance of 23 leading cancer centers that use an expert panel to produce evidence-based guidelines. These guidelines are revised annually and are available for supportive care of specific diseases


The NCCN standards of care for distress management include these four areas. 1) Distress should be recognized, monitored, documented, and treated. 2) All patients should be screened at initial visit and at appropriate intervals. 3) Screening should identify level and nature of distress. 4) Distress should be managed according to clinical practice guidelines.


Standards of care for distress management were published by the Institute of Medicine (IOM) and the Oncology Nursing Society (ONS) in 2008. This was almost ten years after the NCCN initial guidelines were published. Also, the American College of Surgeons

Commission on Cancer has developed new standards. ONS endorsed, in conjunction with APOS and AOSW has developed a joint position statement “Implementing Screening for Distress.”


Distress is important because it influences cancer and its treatment. An IOM report from 2008 states that survivors tell us their psychological concerns were as important as their physical concerns, and that they were often not recognized or addressed by their cancer care providers. Distress affects quality of life, treatment adherence, and survival.


Lifespan risk factors for distress among highest risk include: women; young; greater than 80 years old; poor; marginally educated; history of emotional or social problems. Increased risk of distress is noted  in people with a history of psychiatric disorder or substance abuse;

of the future; impaired physical functioning; time since diagnosis;

cancer type; confusion/delirium; poorly controlled pain; presence of deficit symptoms; feeling like a burden to others; loss of autonomy; and desire to control one’s own death. In patients with moderate of severe distress, suicidal ideation should be addressed. Some cancer patients experience a desire for a hastened death. Suicidal thoughts are relatively common with a review by Cooke, et al, 2013 found a 21% rate of suicidal ideation.


Nurses often recognize that they have limited skill and experience and are often uncomfortable with suicide assessment. Asking questions   to the patient about suicide is important in assessment. Nurses need to practice the appropriate words and statements used with suicide assessment.


Psychosocial interventions for distress are addressed by ONS with Putting Evidence into Practice (PEP) recommendations. PEP interventions are available for the topics of anxiety and depression.


Distress doesn’t end when active treatment ends. Survivor considerations include distress with the continuing of chronic treatment; post treatment; integration of a new normal; and adherence of surveillance. Nurses have identified barriers that include: time to screen; privacy; authority to make decisions; comfort with emotional discussions; and availability of referral resources that are available immediate and in the community.


In conclusion, oncology nurses are key to achieving quality psychosocial care for patients. We can screen, identify concerns, provide resources, and consistently convey the importance of our patient’s emotional well as physical well-being.


Michigan Cancer Consortium

Summarized by Heather Lowry, RN, MSN, WHNP-BC



“The MCC provides a forum for collaboration among its members to improve cancer outcomes for Michigan residents”.  www.michigancancer.org


The topics presented at the meeting included:


The American Cancer Society –Cancer Action Network (ACS- CAN) is working on trying to reinstate the cancer prevention funds that have been wiped out by the Michigan government. An action campaign is in progress along with lobby day, scheduled for April 22. CAN is working to oppose HB 5393, which would allow minors access to e-cigarettes. ACS-CAN is working to help get this and other tobacco products out of the hands of children to protect the public health. Additionally they are working to help pass a bill for exercise recommendations for school age children.


The Michigan Department of community health (MDCH) Tobacco section presented a disturbing look at what e cigarettes really

are. E cigarettes are often presented as a smoking cessation tool which is false. They are a device which is used to inhale vapor, nicotine or other substances and other flavorings or additives (i.e. propylene glycol). There are reports of deaths from poisoning from the e-cigarette as well as from the liquid nicotine. There

are many consumer safety concerns regarding the e-cigarettes, including risk of fire, explosions, poisoning, enabling the discrete use of other drugs and hazardous waste. There is a lack or quality



control and regulation of these devices. The FDA is planning a draft to be released to prohibit the sale of e-cigarettes to minors.


The expansion of the State of Michigan Medicaid program will begin April 1 with the new Healthy Michigan Plan. Enrollment will begin April 1. Requirements include a benefit waiver. Eligibility

is for persons age 19-64, not receiving or eligible for Medicare or current Medicaid, not pregnant and meeting other federal regulations (i.e. citizen, resident of MI). Covered services are

based on federal benchmarks of 10 essential health care services. This is a comprehensive plan and includes dental , cancer, vision, hearing aids and prescription services. This is a cost-sharing health plan, with a contribution of 2% of annual income. Cost is decreased with participation in healthy behaviors. Patients can apply at www.michigan.gov/healthymichiganplan or can call a toll free number.


The lung cancer early detection workgroup has reconvened and will look at lung cancer screening guidelines and

recommendations from multiple agencies for Michigan residents. Looking at promoting public awareness of recommendations.


MCC is looking at the COC recommendation of Survivorship  Care Plans. There is a workgroup looking at how to help agencies implement this standard.

National Cancer Minority Awareness week is April 13-19.  The MCC website provides more detailed information on the

MCC. Cancer control reports, plans facts sheets and resources also

accessible on their web site at www.michigancancer.org.




From the President

Gayle Groshko, RN, BSN, OCN



As I reflect on this past Oncology Nurses month, I recall a recent  Medscape.com article: TheNeedtoNursetheNurse:EmotionalLaborintheNeonatalIntensiveCareUnit.What drew me to the article was not the Neonatal Intensive Care reference but rather the acknowledgement that what we do is “emotional labor” and we need to “nurse the nurse”. In this article I learned a new word.

Eccedentesiast (pronounced ex-cen-dent-tee-shee-ist). In the literary sense it means someone who fakes a smile and is often referenced with T.V. personalities and politicians. In the true sense, it is someone who hides their emotions behind a smile. Oncology nurses do this

all the time. We greet that visitor at the nursing station with a smile, open and caring-even though we just dealt with an angry patient over the delay in transportation from his radiation treatment to

his room. We approach the next follow up patient with a smile and encouragement even though we are crying inside with our most  recent follow up patient; the young mother of two who has just learned her breast cancer has recurred. We may be sitting on an exam room stool holding the hand of a patient that despite our best efforts, continues to rate his pain as 9/10.


Nurses drawn to oncology are compassionate people. We strive daily to help our patients live as well as they can for as long as they can.

We see it as our duty to alleviate pain and suffering. And if we are successful, even in just some small way, we have a sense of “job well done”. But as oncology nurses we are also vulnerable. Many of our patients we know for months and years. We develop relationships with patients and families that make the boundary line between patient and professional very thin. And their loss is our loss. We become susceptible to burnout and compassion fatigue. Burnout generally develops over time and is more related to system issues; inadequate staffing, high patient acuity, diminished resources and support and can lead to compassion fatigue. Charles Figley, PhD describes compassion fatigue “as the cost of caring for others in emotional pain”. The solution for this is simple, really. We need to take care of ourselves and each other. Regular exercise and massage are great stress reducers. Adequate sleep and good nutrition, areas   we often sacrifice and neglect, are essential to our personal wellbeing. Take part in hobbies. Find activities that replenish the mind and spirit. As Debra Mattison so eloquently stated at the President’s Dinner, spirituality does matter. Spirituality speaks to connectedness. We need to ask ourselves: what encourages us? What comforts us?

With whom are we connected? How do we feel nurtured? Hopefully, we have to look no further than office mates, co-workers and colleagues to be Oncology Nurses: First in Hope First in Care. For ourselves and each other, not just our patients.


Identifying, Preventing, and Treating Serious Side Effects Leading to Termination of Therapy in Lymphoma

Presented by Barbara Rogers CRNP, MN, AOCN, ANP-BC Summarized by Patricia DuLong, RN, BA, OCN



In this interesting presentation, Barbara focused on five case studies encompassing side effects of treatments for lymphoma.


The first topic was neutropenia. It is often the most common toxicity in patients with hematologic malignancies. She reminded us that the neutropenia can also be caused by non- malignant illnesses. Common causes of neutropenia include chemotherapy cytotoxic drugs causing bone marrow suppression, radiation to iliac crest and the disease itself. Other causes include other non-antineoplastic drugs so it is important to be aware of the other

medications that patients are taking.



months after completion. Bortezomib peripheral neuropathy usually presents as painful achy leg syndrome or in the hands. It occurs in about half of patients being treated. There is a lower risk of peripheral neuropathy with subcutaneous administration. Brentuximab vedotin has about 48% incidence of patients reporting neuropathy. It is important for nurses is to listen to the patient and evaluate how

the neuropathy affects activities of daily living including how well they can pick up a coin, or tie their shoe and button their clothes.

The grading of the neuropathy helps to modify the dose reductions appropriately. There are drugs that might help reduce the neuropathic pain such as gabapentin and opioid combinations.


Infusion reactions/hypersensitivity reactions (HSRs) involve the immune system and is difficult to differentiate between anaphylactic and anaphylactoid. There are two main types- immediate-occurring within an hour and non-immediate- occurring after one hour.

Immediate manifestations can include urticaria, angioedema, rhinitis, conjunctivitis, bronchospasm, or overt anaphylaxis caused by IgE.

Non-immediate manifestations can be cutaneous symptoms such

as latent urticaria, maculopapular eruptions, vasculitis, Stevens-Johnson

Drugs that may cause neutropenia include: analgesics like dipyrone; antiepileptic agents like valproic acid; anitimicrobial agents like dapsone and penicillins; antithyroid drugs

Management of neutropenia is usually done with myeloid growth factors.

syndrome or drug reaction. These symptoms are due to T-cell mediation. Drugs that have an increased risk of this occurring are chemotherapeutic agents such as platinum, taxanes,

like carbimazole, methimazole, and propylthiouracil; cardiovascular medication like procainamide, and ticlopidine; psycotrophic medications such as clozapine.


Management of neutropenia is usually done with myeloid growth factors. Filgrastim only has a half-life of 3.5 hours so is given several days until the absolute neutrophil count (ANC) recovers. Pegfilgrastim has a half-life of 15-80 hours and given as one subcutaneous injection 24 hours after completion of chemotherapy. These drugs are given from start of treatment if there is greater than 20% predicted incident of neutropenia with the chemotherapy or if the patient experiences febrile neutropenia. Nursing interventions to prevent infection are educating patient on good hand washing, frequent mouth care, and safe handling of food as well as notifying the health care team for a temperature of 100.4 or higher. Additional measures to be observed while a patient is in the hospital include: following policy on catheter placement, IV line changes and central line dressing and access. Some higher risk patients may also be put on antimicrobial prophylaxis.


Chemotherapy induced peripheral neurotoxicity (CIPN) can present a dose limiting event for patients. The agents associated with CIPN are platinum agents; vincas; taxanes; bortezomib, thalidomide, and bentuximab vedotin. With platinum induced CIPN, symptoms can progress for 2-6 months after stopping the drug. Oxaliplatin CIPN can reverse in hours or days but persistant neuropathy may take 6-8 months after completion of the drug and only 40% of those affected will experience complete resolution of the symptoms. Vinca alkaloid CIPN can present with decreased and or loss of deep tendon reflexes. If treatment with the drug continues, muscular weakness can occur.

Sometimes, the CIPN can present with colicky abdominal pain with constipation a few days after treatment. Taxanes present with

paresthesia, numbness and or pain in hands and feet that can include impairment of deep tendon reflexes. The incidence and severity usually related to cumulative doses of 1000mg/m2 for paclitaxel and 400mg/m2 for docetaxel. Symptoms improve within the first 3-6

procarbazine and asparaginase. Monoclonal antibodies is the second class of drugs at risk for infusion/hypersensitivity reactions including rituximab, trastuzumab, panitum salts, bevacizumab and alemtuzumab. The platinum salts usually develop after the sixth

treatment and respond usually with antihistamines. Taxane reactions are usually type 1 due to cremophor but only less than 4% experience the reaction if premedications of antihistamine and steroids are given. The reaction usually occurs in first few minutes after the infusion starts. Symptoms include dyspnea, hypotension, bronchospasm, urticaria and erythematous rashes. Monoclonal antibodies cause   more than half of all HSRs. Retuximab is the most common cause  with 27% experiencing a reaction followed by paclitaxel where 10% experience a reaction. The monoclonal antibody drug reactions are cytokine mediated. The reactions may be managed by stopping drug, giving H1/H2 inhibitors and then restarting the drug at slower rate.


Drug Interactions were the final side effect presented with the case studies. Nurses need to be aware of drug-drug interactions with chemotheraputic agents most commonly impacting the cytochrome P450 enzymes. Many people are taking herbs, supplements and complementary and alternative medicine (CAM) therapies that  may interact with the chemotherapy the patient is receiving. A   good assessment of all the things the patient may be taking at home over the counter is essential. Many patients do not think to tell the

practitioners about their use of over the counter medications because they were not perscribed. Drug interations with tyrosine kinase inhibitors, imatinib, dasatinib and nilotinib are common. These  drugs can inhibit the metabolism some chemotherapy and imatinib can increase absorption as well as lower clearance of acetaminophen which can lead to hepatotoxicity and liver failure.


Knowledge of the prevention and management of neutopenia, neuropathy, infusion reactions and drug interactions can optimize  the treatment and minimize the toxicities experienced by the patients with lymphoma.


Pharmacology Update: Integrating Advances into Practice

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Expand your knowledge on the latest pharmacology issues affecting your practice during ONS’s new e-conference

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