New EORTC guidelines for the treatment of anaemia in patients with cancer: implications for nursing practice.

Anaemia and associated fatigue are common problems in patients with cancer, and fatigue is considered by patients with cancer to be their most limiting symptom. The introduction of erythropoiesis-stimulating proteins (ESPs) has greatly improved the management of anaemia; however, many European patients with cancer-related anaemia are untreated because of a lack of awareness among healthcare professionals of the benefits of anaemia treatment to patients, or because of regional differences in treatment practices. Recently, the European Organisation for Research and Treatment of Cancer (EORTC) developed the first European evidence-based guidelines for the use of ESPs in cancer-related anaemia in order to facilitate and standardize the assessment and management of the condition. These guidelines, and the implications for oncology nurses in implementing them in practice, are discussed.

Cancer-related anaemia and fatigue: assessment and treatment.

Anaemia is common in patients with cancer, but is often under-diagnosed and under-treated. Fatigue is frequently associated with cancer-related anaemia and has a significant impact on patients' quality of life. Many patients regard the treatment of fatigue as more important than the treatment of pain, in contrast with the opinions of many physicians. Accurate assessment of anaemia and fatigue is essential to understand the reality of living with cancer-related anaemia and provide optimal treatment. Oncology nurses are ideally placed to play a key role in the identification and management of cancer-related anaemia by anticipating and assessing the problem during all stages of treatment. Further education on anaemia and fatigue is required. Accurate and detailed training programmes, developed from specific needs analyses, will further enhance the role of oncology nurses.

Nausea: the neglected symptom?

Advances in antiemetic therapy over the past decade have undoubtedly eased the burden of radiotherapy- and chemotherapy-induced nausea and vomiting. Despite this, these distressing side-effects of cancer therapy are still experienced by some patients. Moreover, nausea has both a higher incidence and a greater effect on patient quality of life than vomiting. The impact of nausea may therefore warrant more attention than perhaps it has received previously, and there is undoubtedly room for improvement regarding its treatment. Recognizing and treating nausea is complicated by the fact that it can only be measured subjectively by the patient rather than objectively by clinical staff. However, various patient-centred strategies may be employed by nurses to ensure self-reporting of the occurrence and impact of nausea. Nurses may also be best placed to identify patient-related prognostic factors in order to determine the risk of nausea. Antiemetic guidelines recommend the use of a 5-HT3-receptor antagonist for the control of emesis with moderate and highly emetogenic cancer therapy. Although guidelines do not distinguish between the available agents, pharmacological differences do exist, and it is necessary to consider this when tailoring regimens to individual patients. As with any therapy, less complicated dosing regimens are likely to improve compliance, an issue that may be particularly pertinent in nauseated patients who are unable to ingest multiple doses. Furthermore, the focus of antiemetic therapy should be on prevention, as the presence and severity of acute symptoms have been linked to occurrence of symptoms in the delayed phase and the likelihood of anticipatory nausea and vomiting with further treatment cycles. This review aims to assess the potentially neglected symptom of nausea and focuses on recognizing and controlling this side-effect of cancer therapy.

Knowledge of haematological toxicities amongst European nurses--a learning needs assessment.

Haematological toxicities such as neutropenia, anaemia and thrombocytopenia have a significant impact on patients with cancer. They can have a life-threatening effect on the health of the patient and, importantly, may lead to the interruption and/or dose reduction of ongoing cancer therapies, such as chemotherapy. Nurses play a pivotal role in haematological toxicity prevention, detection and management, however, the current level of involvement and understanding varies widely across Europe. Continuing Professional Education (CPE) is an important tool in maximising nurses' contributions to such healthcare issues, enabling them to maintain awareness of recent research, refreshing their knowledge, and facilitating consistency of best practice. As such, the European Oncology Nursing Society (EONS) is developing a Europe-wide training programme in haematological toxicities. This is based on the unmet CPE needs identified through a Learning Needs Assessment (LNA) carried out amongst European cancer nurses in 2003. This article discusses the results of the LNA and how the key issues that it has revealed are being addressed in EONS' nurse education programme, 'Training Initiative in Thrombocytopenia, Anaemia and Neutropenia (TITAN)'.

Anemia impact and management: focus on patient needs and the use of erythropoietic agents.

Anemia is a common complication associated with cancer and cancer treatment. As many as 50% to 60% of cancer patients will develop this condition. Fatigue is a major symptom of anemia and is a primary complaint in patients with cancer. Fatigue can be debilitating for patients, reducing their ability to work, decreasing physical and emotional well-being, and interfering with cognitive ability, all of which can lead to anxiety and depression. Despite the high incidence of the disease and the extent of its impact on the cancer patient, anemia remains underdiagnosed and undertreated. Erythropoietic proteins offer a valuable alternative to standard transfusion therapy, and there is increasing evidence that, in addition to raising hemoglobin levels, these therapeutic agents can lead to improvements in quality of life and patient-reported outcomes. The impact of anemia correction on survival is under investigation; a body of evidence suggests a possible benefit, although this has recently been challenged. There is a strong need for increased awareness of cancer-related anemia and the consequences of its lack of treatment.

Intraclass correlation metrics for the accuracy of algorithmic definitions in a computerized decision support system for supportive cancer care.

As part of the development of a computerized clinical decision support system for anemia management in cancer patients, we applied psychometric principles and techniques to assess the accuracy of the algorithmic operationalizations of a set of evidence-based practice guidelines. In an iterative rating process, five medical and nursing experts rated 27 algorithmic sets derived from 18 guidelines, the objective being an intraclass coefficient (ICC) exceeding 0.90. The first round of review yielded an ICC of 1.00 for 22 sets. After revision and resubmission to the expert panel, an ICC of 1.00 was obtained for the additional five sets. The evolving decision support system is based on algorithms that accurately specify evidence-based guidelines for anemia management in cancer patients.

Comparison of proposed diagnostic criteria with FACT-F and VAS for cancer-related fatigue: proposal for use as a screening tool.

The objective was to validate the use of the proposed International Statistical Classification of Diseases and Related Health Problems (10th revision) (ICD-10) criteria for fatigue (P-ICD10) through comparison with the Functional Assessment of Cancer Therapy Fatigue (FACT-F) subscale and three visual analogue scale (VAS) qualities in cancer patients thought to be fatigued. Fatigue was assessed in 834 cancer patients at three clinical centres in Belgium, using P-ICD10, FACT-F, and VAS to assess: level of energy (VAS1), quality of life (VAS2), and ability to perform daily activities (VAS3). Of the 834 interviewed cancer patients, 54% were classified as fatigued by the P-ICD10 criteria. Internal consistency of P-ICD10 was very good (alpha coefficient 0.82). The principal component analysis corroborated good internal consistency with all variables included in the first component; a second component was used to identify psychological fatigue (concentration and short-term memory disabilities). An abridged set of screening tools based on the first three general symptoms of the P-ICD10 is proposed with 100% specificity and 86% specificity, respectively. There was a marked decrease in FACT-F and VAS1 scores in patients diagnosed as fatigued by the P-ICD10 (mean+/-SD, FACT-F 20+/-9 vs 39+/-8, VAS1 34+/-21 vs 61+/-21). A logistic regression model between P-ICD10 criteria diagnosis and FACT-F (VAS1) identified a score of 34 (61) on the FACT-F scale as a proposed cut-off point for the diagnosis of fatigue. The ICD-10 criteria can be recommended as a diagnostic tool, whereas the FACT-F scale and the level of energy 100-mm VAS assess the intensity of fatigue, and are more suitable for follow-up of cancer-related fatigue.