NE Oncology Issue – November 2006

Oral and gastrointestinal mucositis are common symptoms related to chemotherapy. As stated by Dr. McGuire, the guidelines outlined by Brennan et al.1 for the assessment and management of mucositis are very important, and need to be kept in mind during mucositis symptom management. Nausea and emesis are other symptoms that are commonly observed in patients undergoing cancer treatment. Defining nausea can be subjective, and it is therefore difficult to develop guidelines for its management. Control of emesis is imperative since it can affect patients’ ability to receive cancer therapy, and hence, patient outcomes. Newer drugs in the 1990s changed the way emesis is managed in patients with cancer. The level of evidence for thevarious anti-emetics available varies, and Dr. Grunberg’s work in this area is therefore very important.

Chemotherapy-induced anemia is also commonly seen in patients undergoing cancer treatment. Treating underlying anemia can significantly improve quality of life. Blood transfusion is one way of treating underlying anemia but this is a drastic and expensive measure. Moreover, there are people who would refuse a blood transfusion for religious and other reasons, such as fear of contracting blood-borne infections. It is more advisable to find other ways to manage anemia. Cancer Care Ontario guidelines recommend erythropoietin to be a safe and effective treatment option if given with the intent of reducing the incidence of symptomatic treatment-related anemia and the need for red blood cell transfusion, and as a reasonable treatment option in patients in whom a slow decline in hemoglobin is associated with increased fatigue and perceived a reduction in quality of life.3 More information on managing fatigue and other symptoms can be obtained from the Oncology Nursing Society (ONS) and Cancer Care Ontario.4,5 Ms. Donovan’s chemotherapy sideeffect management interactive toolkit for nurses will also be very useful in evaluating and managing these symptoms.

Fatigue as a result of cancer treatment has been known for many years. In the early 1990s, the attitude among healthcare professionals was that fatigue was an unavoidable part of the cancer treatment process. In recent years, however, management of fatigue has become an important component of symptom management in supportive care. Dr. Ann Berger and Dr. Marlies Peters both addressed this issue in their presentations. Questions such as “What are the usual activities in your daily life?” are very important for elucidating answers that will help us design appropriate interventions for fatigue management.

A noteworthy point that was raised in this meeting was the need to inform patients of all the choices in symptom management treatment. There is a legal requirement in Canada to inform patients of all treatment resources whether they are funded by the provincial government or not. Nurses need to be aware of which drugs are funded so they can direct the patient to the person who can give them the information they need. In our hospital at Oshawa, a Symptom Management Coordinator provides this service. Patients themselves can play an active role in symptom management, and this is where the PRO-SELF model for symptom management that Dr. Dodd helped develop is useful. It is being widely used in hospitals across the US and it can easily be adopted in Canada. The tool might need to be modified according to the hospital’s needs, however.

In my opinion, algorithms to determine the risk of developing neutropenia as described by the CARE team and in several poster presentations, would be a very useful tool for nurses. Having direction provides a security blanket for the healthcare professional, helps in maintaining consistency in symptom management and in turn contributes to patients’ well-being. We are developing similar tools here in Canada. Ms. Tracy Nagy at the Princess Margaret Hospital in Toronto has developed a documentation tool and algorithm that provides a framework that supports more autonomous, consistent, and efficient practice at the bedside.6

In our centre in Oshawa, we provide individualized symptom management for patients with cancer. The study by Dr. Peters was therefore of great interest. There is a relationship between anxiety, the irregularity and dysregulation of sleep patterns, and fatigue. The modules in Dr. Peters’ presentation build on each other and link up very nicely to Dr. Berger’s presentation. Patients need to be educated about managing their energy levels to prevent fatigue. An interesting observation from my doctoral work was the relationship between social support and fatigue. I was studying the quality of life issues in patients undergoing treatment for lung cancer and I found that it was related to the level of support they were receiving. Patients that perceived a need for more support felt more helpless and that feeling of helplessness led to a poorer quality of life. The quality of support that is given to patients is therefore of utmost importance. As Dr. Peters stated, patients need to be encouraged to be more self-sufficient and their family members need to be more involved. Providing patients with a telephone number that they can call with their questions and concerns is important in helping them feel psychologically secure, even if they won’t necessarily use it.

References: 1. Brennan MT et al. Alimentary mucositis: putting the guidelines into practice. Support Care Cancer 2006;14:573–79 2. Grunberg SM et al. Evaluation of new antiemetic agents and definition of antineoplastic agent emetogenicity—an update. Support Care Cancer 2005;13:80–4 3. The role of erythropoietin in the management of cancer patients with non-hematologic malignancies receiving chemotherapy practice guideline report #12-1. Available at http://www.cancercare.on.ca/pdf/pebc12-1s.pdf 4. The Oncology Nursing Society (ONS) website. The Putting Evidence into Practice (PEP) resource page. Available at http://www.ons.org/outcomes/PEPcard/index.shtml. Accessed on October 11, 2006 5. The Cancer Care Ontario Website. The Telephone Nursing Practice and Symptom Management Guidelines page. Available at http://www.cancercare.on.ca/documents/NursingTelephonePracticeGuidelines.pdf 6. Nagy T. Abbreviated infusion rituximab: lessons learned and ways forward. ONS Annual Congress Abstracts 2006. Abstract #79

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Contributors

dr.lemonde
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.

dr-ellis
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.

dr-clemons
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.

dr-cole
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.

dr-sehdev
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.