NE Oncology Issue – November 2006

Meenakshi Kashyap

Patients with cancer experience a range of symptoms, many of them simultaneously, as a result of their disease or as a result of treatments for their disease. The proper management of these symptoms is vital, since unrelieved symptoms can compromise patient outcomes.

In collaboration with other healthcare professionals, nurses are concerned with understanding and responding to diverse patient experiences of cancer; for example, distress, fear, fatigue, nausea, mucositis, pain, or neutropenia. The scope of nursing practice and its location in the system means that nurses are integral to identifying an individual’s supportive care needs and engaging an appropriate team response to address these needs. This article highlights some of the presentations relating to Evidence-Based Symptom Management and supportive care at the recent ICCN meeting.

Evidence-Based Symptom Management

During the plenary session on Evidence-Based Symptom Management, Dr. Deborah McGuire (University of Maryland School of Nursing, USA) briefly reviewed the 2005 update of the MASCC mucositis guidelines. The process involved the creation of inter-disciplinary groups that focussed on specific topics and then conducted a coordinated literature search with the help of medical librarians. They rated levels of evidence in research articles and patient outcomes and these ratings were used to formulate guidelines based on evidence and group consensus. All work groups published their papers in the June 2006 issue of Supportive Care in Cancer. A summary paper was also prepared for the journal Cancer. The components of the guidelines are within the scope of nursing practice, are easy to implement and evaluate, and are applicable in many settings. Dr. McGuire discussed the application of these guidelines and suggested that they be collaborative to ensure that pretreatment dental care for any dental issues, initiation of systematic oral care protocol using a soft toothbrush with regular replacement of the toothbrush to prevent infection, flossing, rinsing, use of topical anesthetics, intravenous morphine if needed, and regular oral assessments all follow a course of mucositis.

Ms. Rebecca Clark-Snow (University of Kansas Cancer Center, USA) spoke about the use of anti-emetics guidelines. Control of emesis allows chemotherapy treatment to be administered and antiemetics continue to be crucial in the treatment of patients with most malignancies. Newer agents have significantly improved control of both acute and delayed emesis. The Perugia International Cancer Conference VII, held in 2004, was a consensus meeting on anti-emetic therapy. The official process was subscribed to by nine international oncology groups that included MASCC internationally, ASCO, ONS, NCCN in the US, CCO in Canada, ESMO and EONS in Europe, SASMO in Africa, and COSA in Australia. Each group worked on its area of concentration prior to the meeting. Changing an existing guideline required compelling evidence based on well-conducted trials, generally with a comparator felt to be consistent with guidelines and representing best practice. In addition, anti-emetic treatment guidelines were assigned for the four emetic risk groups: high, moderate, low, and minimal (Tables 1, 2, 3, 4).

The Robert Tiffany lecture was presented by awardee Dr. Marylin Dodd (University of California, San Francisco, USA). Dr. Dodd presented a brief overview on the importance of symptom manage–ment in patients with cancer and discussed the merits of the PRO-SELF program. Dr. Dodd stated that information given to patients should be relevant, timely, and comprehensive but not overwhelming. Patients should be encouraged to engage in self-care exercises, and there should be consistent and timely evaluation of the effectiveness of the program, which means that supportive, interactive nursing care should involve listening to the individual’s experience. Dr. Dodd listed results from some of the studies that utilized the PRO-SELF program to manage oral mucositis, pain, and fatigue. We are only beginning to understand the pathobiology of mucositis.1 Mucositis is an acute phenomenon that is resolved once cancer therapy has ended, though the tissues involved may never be the same. One study targeting prevention of oral mucositis followed 200 patients. All participants followed a prescribed oral hygiene program, and were randomly assigned to three mouthwashes: salt and soda, chlorhexidine, and “magic” mouthwash. The patients were provided with information on mucositis, self-care exercises, and supportive interactive nursing care. An interesting observation from this study was that while there were no significant differences among the three groups, there was a reduction in the overall incidence of mucositis in the entire sample.2

The PRO-SELF pain control study compared the effectiveness of the PRO-SELF pain control program (PSPC) to standardized care in decreasing pain intensity scores in patients with cancer.3 Patients in the standard care arm (PSPS) were assessed by a re-search nurse in person, and were called three times by phone between the home visits. The PRO-SELF group patients by contrast were assessed by specially trained intervention nurses, educated in self-care, taught how to use a pillbox, and given written instructions on how to communicate with their physician about unrelieved pain and the need for changes in their analgesic prescriptions. The study found a significant decrease in pain intensity scores in the PSPC group (P<0.0001), and a significant increase in opioid intake to 50 mg/d by the PSPS group.

Ms. Gill Donovan (Director of Patient Services, Tenovus, UK) provided a brief overview of the management of chemotherapy side effects. The Cancer Resource and Education (CARE) team, a group of oncology nurses, utilizing an unrestricted educational grant from Sanofi-Aventis, has developed a chemotherapy side-effect management toolkit for nurses. This toolkit is available on a CD-ROM, is interactive, and contains a telephone protocol form, initial nursing assessment proforma, a core presentation slide kit, patient case studies, evaluation forms, a review article, a test-your-knowledge section, side effect algorithms that provide symptom-by-symptom management strategies—encompassing assessment of patient status, treatment recommendations, and advice to patients (Figure 1)—and references.

Tools for Treatment-Related Side Effects

Several posters in the area of supportive care presented tools that nurses could use to manage treatment-related side effects. One such poster was by Ms. Kelley Moore and Dr. Barry Fortner (Supportive Oncology Services, Memphis, USA). The authors described the utility of a chemotherapy induced neutropenia (CIN) risk-assessment tool that was developed by the Assessment Information Management (AIM) Higher initiative for use in the clinical oncology setting. The tool was designed to assess the most common patient risk factors and actions taken in response to the findings in the risk assessment.4 Eighty-seven percent of the nurses who participated in the study said that the CIN risk-assessment tool was easy to use and that it helped them determine which patients were at risk for CIN in 67% of the cases. Because not all risk information is con-sistently present in the patient chart pretreatment, a majority of the nurses that participated in this study felt this tool could provide a framework for nurses to ask additional questions during the patient interview, and thus assist them in prompting interventions to prevent or lessen the severity of CIN and its complications in those patients at risk of CIN.

The poster by Ms. Cathy Maxwell and Ms. Alisha Stein (Advanced Medical Specialties, Miami, USA) discussed the implementation of the National Comprehensive Cancer Network (NCCN) practice guidelines for managing neutropenia through the development of algorithms by Florida Cancer Consultants and by developing standing orders at Advanced Medical Specialties.5 The authors provided simplified guidelines for common lengthy policies and procedures which help improve practice efficiency by reducing the human resource burden of managing chemotherapy induced neutropenia and its complications (Figures 2 and 3). The guidelines also provide useful data for collecting and analyzing patient outcomes and facilitate makingdecisions through practical, effective, and clearly defined methods and tools.

The importance of the role nurses play in symptom management was highlighted in the session, “Supportive Care: Symptom Management.” This session addressed the various ways in which nurses could play an active role in managing patient symptoms. Dr. Ann Berger (University of Nebraska, USA) discussed fatigue and factors associated with fatigue prior to beginning adjuvant breast cancer treatment.6 An earlier study by Dr. Berger’s group7 and Ancoli-Israel et al.8 had reported mild fatigue and disturbed sleep prior to treatment in women with cancer. Dr. Berger’s recent study was a randomized clinical trial with patients being treated for stage I–IIIA breast cancer (n=131) randomly assigned to receive an individualized sleep promotion plan and healthy eating information. Patients were monitored by wrist actigraphy for a continuous 48 hours. Her study revealed that sleep quality and anxiety were the two variables that influenced fatigue significantly. A stepwise regression analysis determined the Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale anxiety to be significantly associated with higher Piper Integrated Fatigue model scores (F=21.29, P<0.001). Higher baseline fatigue was associated with poorer subjective sleep quality and higher levels of anxiety. The key message from the study was that sleep intervention aimed at reducing pre-chemo-therapy anxiety and improving sleep needs to begin prior to treatment.

Dr. Marlies Peters (Radbound University, The Netherlands) discussed the importance of assessing fatigue in cancer survivors.9 The Expert Centre for Chronic Fatigue (ECCF) of the Radbound University Nijmegen Medical Centre has developed a treatment for fatigue in patients with cancer based on the principles of cognitive behavioural therapy (CBT), which is carried out by psychologists. Ninety-nine percent of patients during treatment and 30–40% of cancer survivors still suffer from fatigue. However, as Dr. Peters explained, there are precipitating, perpetuating, and predisposing factors associated with cancer and fatigue. The precipitating factors are the disease itself, and treatment for the disease. Predisposing factors are the onset of fatigue before development of cancer. Perpetuating factors of fatigue include insufficient coping mechanisms to deal with the experience of cancer; fear of disease recurrence; irrational cognitions of fatigue; irregular sleep/wake rhythms; reduced physical activity levels; and insufficient social support and social interactions. Two groups of patients undergoing cancer treatment were randomly assigned to either the CBT group (n=50) or a group that was waitlisted for six months, and then offered CBT (n=48) where predisposing and perpetuating factors for fatigue were assessed. Data was gathered from 38 patients in the CBT group and 44 patients from the waitlisted group. A scale of 35 and over on the Checklist Individual Strength (CIS) fatigue severity scale was used to assess fatigue. Seventy-six percent of patients in the CBT group said they were not fatigued while only 21% of the waitlisted group said that they were not fatigued, suggesting that CBT has an important role to play in symptom management.

In summary, a recurring theme in this year’s ICCN conference was the need for educating patients about their symptoms, encouraging them to participate in self care, developing individualized symptom management plans, and most importantly, developing tools and algorithms that healthcare professionals can use for symptom management.

References: 1. Sonis TS. The pathobiology of mucositis. Nat Rev Cancer 2004;4:277–84 2. Dodd MJ et al. Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis 2000;90:39–47 3. Miaskowski C et al. Randomized clinical trial of the effectiveness of a self-care intervention to improve cancer pain management. J Clin Oncol 2004;22:1713–20 4. Moore K, Fortner B. A study on the feasibility of having nurses evaluate patients for chemotherapy-induced neutropenic complications using a risk assessment tool. ICCN 2006: Poster 306 5. Maxwell C, Stein A. Implementation of practice guidelines for chemotherapy-induced neutropenia: from paper to practice. ICCN 2006: Poster 330 6. Berger A. Examining fatigue and factors associated with fatigue prior to adjuvant breast cancer chemotherapy treatment within a randomized clinical trial. ICCN 2006: Abstract 0-158 7. Berger AM et al. Feasibility of a sleep intervention during adjuvant breast cancer chemotherapy. Oncol Nurs Forum 2002;29:1431–41 8. Ancoli-Israel S et al. Fatigue, sleep, and circadian rhythms prior to chemotherapy for breast cancer. Support Care Cancer 2006;14:201–9 9. Peters M. Post-cancer fatigue. ICCN 2006: Abstract 0-160.

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Manon Lemonde, MB
Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT
Dr. Manon Lemonde received her PhD in biomedical sciences from the Université of Montréal. She has many publications related to symptom management and social support. She has presented at oncology conferences and was also instrumental in developing workshops on fatigue in cancer. Dr. Lemonde’s oncology research interests are related to quality of life, human health resources planning in terms of recruitment and retention, and work environment.

Peter Ellis, MBBS, MMed (Clin Epi), PhD, FRACP
Associate Professor in the Departments of Medicine and Clinical Epidemiology & Biostatistics, McMaster University
Chair of the Juravinski Cancer Centre Lung Disease Site Team
Executive Member of the National Cancer Institute of Canada (NCIC) Clinical Trials Group Lung Disease Site Committee Dr. Peter Ellis is a staff medical oncologist at the Juravinski Cancer Centre (JCC). He is a member of Cancer Care Ontario’s Practice Guideline Initiative, Provincial Lung Disease Site Group. He is also an investigator on several NCIC and pharmaceutical industry-sponsored multi-centre phase III clinical trials in breast and lung cancer. Dr. Ellis has a research interest in the role of the consumer in decision making, and is an investigator in several studies in this area. He is also co-principal investigator in a systematic review examining diffusion and dissemination of cancer control interventions.

Mark Clemons, MB, BSc, MRCP(UK), MD
Associate Professor of Medicine and Oncology, McGill University Division of Hematology, McGill University Health Centre Head of Breast Medical Oncology, Princess Margaret Hospital
Assistant Professor, Department of Medicine, University of Toronto
Dr. Mark Clemons is a staff oncologist at the Princess Margaret Hospital, Toronto. He has published widely on the management of breast cancer, and has a research program evaluating the mechanisms of resistance and sensitivity to treatment for bone metastases and locally advanced breast cancer.

Dana Cole, BScPharm, ACPR, PharmD
Clinical Pharmacist and Pharmacy Residency Coordinator, Prince George Regional Hospital
Head of Breast Medical Oncology, Princess Margaret Hospital
Assistant Professor, Department of Pharmacology, University of Northern British Columbia
Clinical Assistant Professor, Faculty of Pharmaceutical Sciences, University of British Columbia
Dana Cole’s clinical interests are in supportive care, particularly anemia management, venous thromboembolism and palliative care. She has served as a reviewer for the professional development and assessment program, as a member of the advanced practitioner credentialing committee with the College of Pharmacists of BC, and as a member of the Canadian Association of Pharmacy in Oncology and the Canadian Society of Hospital Pharmacists.

Sandeep Sehdev, MD
Oncologist, William Osler Health Centre, Brampton
Dr. Sehdev is a community-focused medical oncologist at one of Canada’s largest community hospitals. He completed his fellowship at the Princess Margaret in Toronto in 1991, and his clinical practice treats most types of cancer. However, he has a keen interest in breast cancer, lung cancer, and patient education. Dr. Sehdev has been involved in breast cancer clinical trials through NCIC and BCIRG groups and has recently chaired several medical advisory board meetings on the role of hormonal therapy in breast cancer. In particular, Dr. Sehdev has been part of one of the largest and longest running breast cancer trials ever, the ATAC trial.