Peggy S. Burhenn

Using Tools and Technology to Promote Education and Adherence to Oral Agents for Cancer

BACKGROUND The use of oral agents for cancer (OACs) is increasing, and oncology nurses are in an ideal position to educate patients about them and suggest methods to improve adherence. Once an OAC is ordered, the administration is the responsibility of the patient. Oncology nurses can use tools and technology to assist with education, which may promote adherence, and suggest reminder tools that can be used. Many electronic tools have been developed, such as smartphone applications, text messaging, electronic alarms, and glowing pill bottles. OBJECTIVES The researchers reviewed electronic devices, as well as traditional methods such as calendars and pillboxes, that can assist patients in remembering to take the medication they are administering at home. METHODS A literature search was compiled and websites were searched for patient education tools, reminder tools (electronic and manual), and smartphone applications. The project was part of the Oncology Nursing Society Putting Evidence Into Practice effort on oral adherence. FINDINGS Education alone is insufficient to promote adherence to oral medication regimens. Multicomponent interventions have demonstrated improved adherence, and tools and technology directed at improving adherence to oral agents can be used. The researchers found multiple reminder aids to assist patients in adhering to an oral regimen. They are highlighted in this article.

Older adult oncology, version 2.2016: Featured updates to the NCCN guidelines

Cancer is the leading cause of death in older adults aged 60 to 79 years. Older patients with good performance status are able to tolerate commonly used treatment modalities as well as younger patients, particularly when adequate supportive care is provided. For older patients who are able to tolerate curative treatment, options include surgery, radiation therapy (RT), chemotherapy, and targeted therapies. RT can be highly effective and well tolerated in carefully selected patients, and advanced age alone should not preclude the use of RT in older patients with cancer. Judicious application of advanced RT techniques that facilitate normal tissue sparing and reduce RT doses to organs at risk are important for all patients, and may help to assuage concerns about the risks of RT in older adults. These NCCN Guidelines Insights focus on the recent updates to the 2016 NCCN Guidelines for Older Adult Oncology specific to the use of RT in the management of older adults with cancer.

Geriatric assessment in daily oncology practice for nurses and allied health care professionals: Opinion paper of the Nursing and Allied Health Interest Group of the International Society of Geriatric Oncology (SIOG)

The management of older persons with cancer has become a major public health concern in developed countries because of the aging of the population and the steady increase in cancer incidence with advancing age. Nurses and allied health care professionals are challenged to address the needs of this growing population. The International Society of Geriatric Oncology (SIOG) Nursing and Allied Health (NAH) Interest Group described key issues that nurses and allied health care professionals face when caring for older persons with cancer. The domains of the Geriatric Assessment (GA) are used as a guiding framework. The following geriatric domains are described: demographic data and social support, functional status, cognition, mental health, nutritional status, fatigue, comorbidities, polypharmacy, and other geriatric syndromes (e.g. falls, delirium). In addition to these geriatric domains, quality of life (QoL) is described based on the overall importance in this particular population. Advice for integration of assessment of these geriatric domains into daily oncology practice is made. Research has mainly focused on the role of treating physicians but the involvement of nurses and allied health care professionals is crucial in the care of older persons with cancer through the GA process. The ability of nurses and allied health care professionals to perform this assessment requires specialized training and education beyond standard oncology knowledge.

Guided Imagery for Pain Control

Evidence-based practice is integral to the delivery of effective and efficient nursing care. However, translating evidence into practice remains a challenge in health care. To overcome this challenge, the Oncology Nursing Society developed a program, the ONS Foundation Institute for Evidence-Based Practice Change, to provide nurses with the tools they need to translate evidence-based practice to their units. This article reviews the process of implementing the evidence-based practice of guided imagery for pain management on a medical oncology inpatient unit at a comprehensive cancer center.

Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology

Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .

Exercise Promotion in Geriatric Oncology

Evidence of the benefits of exercise for people with cancer from diagnosis through survivorship is growing. However, most cancers occur in older adults and little exercise advice is available for making specific recommendations for older adults with cancer. Individualized exercise prescriptions are safe, feasible, and beneficial for the geriatric oncology population. Oncology providers must be equipped to discuss the short- and long-term benefits of exercise and assist older patients in obtaining appropriate exercise prescriptions. This review provides detailed information about professionals and their roles as it relates to functional assessment, intervention, and evaluation of the geriatric oncology population. This review addresses the importance of functional status assessment and appropriate referrals to other oncology professionals.

Support for Patients and Family Caregivers in Lung Cancer: Educational Components of an Interdisciplinary Palliative Care Intervention.

Consistent with the recommendations of the Institute of Medicine Report on quality cancer care, attention to symptom management and quality of life concerns of patients with lung cancer should be addressed throughout the disease trajectory. As part of an National Cancer Institute-funded Program Project grant, this article reports on the patient and family caregiver education component of a nurse-lead, tailored, palliative care intervention for patients with early-stage (I-III, n = 130) and late-stage (IV, n = 142) lung cancer. Patients and family caregivers received 4 separate educational sessions organized around the Quality of Life model domains (physical, psychological, social, and spiritual well-being). Each patient and caregiver was presented at a weekly interdisciplinary case conference, which also informed the educational sessions. Based on needs and team suggestions, an individualized palliative care plan was created and a tailored educational intervention was designed based on topics chosen by each participant. The most common topics chosen by patients in each domain were fatigue, worry and fear, social support/isolation, and hope. Family caregivers most commonly chose fatigue, worry and fear, communication, and purpose and meaning in life. The time spent in each teaching session ranged from 31 to 44 minutes for patients and 25 to 35 minutes for family caregivers. There is a vital need for interdisciplinary palliative care interventions for patients across all stages and across the disease trajectory. Nurses are vital to integrating palliative care into routine care. Providing a tailored educational intervention is an important aspect of palliative care for patients and family caregivers. This article focuses on the process of the tailored educational intervention.

A Trial Examining an Advanced Practice Nurse Intervention to Promote Medication Adherence and Symptom Management in Adult Cancer Patients Prescribed Oral Anti-Cancer Agents: Study Protocol

AIM To report a study protocol that refines then examines feasibility, preliminary efficacy and satisfaction of ADHERE, an intervention using motivational interviewing and brief cognitive behaviorial therapy as a mechanism for goal-oriented systematic patient education to promote symptom management and adherence among cancer patients prescribed oral anti-cancer agents. BACKGROUND Cancer treatment with oral anti-cancer agents shifts responsibility for managing treatment from clinicians in supervised cancer centres to patients and their caregivers. Thus, a need exists to standardize start-of-care to support patient self-management of care at home. DESIGN A two-phase quasi-experimental sequential design with repeated measures. METHODS Sixty-five adult patients newly prescribed an oral anti-cancer agent will be recruited from three community cancer centres. Phase 1 will enrol five patients to refine the ADHERE intervention prior to testing. After completion, Phase 2 will enrol 30 patients who receive usual care. Advanced practice nurses will then be trained. Thirty patients will be then enrolled in the intervention group and provided ADHERE, a 4-week intervention using semi-structured interactions (initial face-to-face session and once a week phone sessions over 3 weeks) and a Toolkit to promote self-management of care. Outcome measures include: oral anti-cancer agents adherence rate, symptom presence and severity, feasibility and satisfaction with ADHERE. This protocol was approved January 2014. DISCUSSION This nurse-led intervention has the potential to standardize the start-of-care training for the patients to self-manage when oral anti-cancer agents for treatment were prescribed.

How do I best manage insomnia and other sleep disorders in older adults with cancer

Insomnia is common in older adults with cancer, with a reported prevalence of 19-60% in prior studies. Cancer treatments are associated with increased risk of insomnia or aggravation of pre-existing insomnia symptoms, and patients who are receiving active cancer treatments are more likely to report insomnia. Insomnia can lead to significant physical and psychological consequences with increased mortality. We discuss physiological sleep changes in older adults, and illustrated the various sleep disorders. We present a literature review on the prevalence and the effects of insomnia on the quality of life in older adults with cancer. We discuss the risk factors and presented a theoretical framework of insomnia in older adults with cancer. We present a case study to illustrate the assessment and management of insomnia in older adults with cancer, comparing and contrasting a number of tools for sleep assessment. There are currently no guidelines on the treatment of sleep disorders in older adults with cancer. We present an algorithm developed at the City of Hope Comprehensive Cancer Center by a multidisciplinary team for managing insomnia, using evidence-based pharmacologic and non-pharmacologic interventions.

A Phase II Trial of Older Adults with Metastatic Breast Cancer Receiving nab-Paclitaxel: Melding the Fields of Geriatrics and Oncology

Micro‐Abstract nab‐Paclitaxel may be an attractive therapy for older adults because of its efficacy, the infrequency of allergic reactions, and the lack of need for steroid pre‐medications. We evaluated the tolerability and efficacy of nab‐paclitaxel in older adults with metastatic breast cancer, as well as the relationship between a geriatric assessment‐based toxicity risk score and chemotherapy toxicity, dose reductions, dose delays, and hospitalizations. Patients with intermediate/high toxicity risk scores had higher risk of grade ≥ 3 toxicity than those with low risk scores, and a higher mean risk score was associated with higher likelihood of dose reductions and hospitalizations. A geriatric assessment‐based risk score can help weigh the risks and benefits of chemotherapy in older adults, and should be incorporated into future trials testing new therapies in this population. Introduction: Phase II clinical trials including geriatric assessment (GA) measures are critical for improving the evidence base for older adults with cancer. We assessed the efficacy and tolerability of nab‐paclitaxel in older adults with metastatic breast cancer (MBC). Patients and Methods: Patients aged ≥ 65 years with MBC and ≤ 1 previous line of chemotherapy received 100 mg of nab‐paclitaxel on days 1, 8, and 15 of a 28‐day cycle. A GA was completed pre‐chemotherapy, and the validated Cancer and Aging Research Group (CARG) chemotherapy toxicity risk score was calculated. Relationships between tolerability (number of courses, hospitalizations, dose reductions, and toxicity) and risk score were assessed using general linear models, Student t tests, and the Fisher test. Response rate and progression‐free survival were evaluated using the Kaplan‐Meier method. Results: Forty patients (mean age, 73 years; range, 65‐87 years) were included. The median number of cycles was 6, 75% (n = 30) of patients had ≥ 1 dose hold, and 50% (n = 20) had ≥ 1 dose reduction. Fifty‐eight percent (n = 23) had treatment‐related ≥ grade 3 toxicities, and 30% (n = 12) were hospitalized owing to toxicity. Thirty‐five percent (n = 14) responded, and the median progression‐free survival was 6.5 months (95% confidence interval, 5.5 months to undefined). Patients with intermediate/high toxicity risk scores had higher risk of grade ≥ 3 toxicity than those with low risk scores (odds ratio, 5.8; 95% confidence interval, 1.3‐33.1; P = .01). A higher mean risk score was associated with higher likelihood of dose reductions and hospitalizations. Conclusions: Among older adults with MBC receiving weekly nab‐paclitaxel, more than one‐half experienced ≥ grade 3 chemotherapy toxicity. However, a GA‐based risk score could predict treatment tolerability.