ONS Guidelines™ to Support Patient Adherence to Oral Anticancer Medications.

PURPOSE: This evidence-based guideline intends to support patients, clinicians, and others regarding interventions and processes to support patient adherence to oral anticancer medications (OAMs). METHODOLOGIC APPROACH: A panel of healthcare professionals and patient representatives developed a clinical practice guideline to support patients taking OAMs. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology and criteria for trustworthy guidelines were followed. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A quantitative or narrative synthesis of the evidence was completed. Certainty of the evidence was assessed using GRADE. FINDINGS: The panel agreed on recommendations and suggested an adherence risk assessment, education addressing adherence, ongoing assessment, proactive follow-up, coaching, and motivational interviewing in addition to usual care. The panel suggested the implementation of a structured OAM program. IMPLICATIONS FOR NURSING: As cancer treatment shifts from clinic to home settings, interventions and programs to support patients on OAMs are needed.

Implementing the Condensed Memorial Symptom Assessment Scale on an Inpatient Oncology Unit.

BACKGROUND: Symptom distress places a burden on patients and their families, but it is often not captured in nursing documentation. Using a symptom management tool, such as the Condensed Memorial Symptom Assessment Scale (CMSAS), can assist in this capture and link patients to resources. OBJECTIVES: The purpose of this quality improvement (QI) project was to implement the CMSAS and capture symptom burden to create a streamlined method of documentation. METHODS: A QI pilot was conducted on an inpatient oncology unit implementing the CMSAS. Then, surveys were provided to the patients to complete at admission and discharge. The most distressing symptoms patients reported were added into the electronic health record nursing care plan that automatically uploaded interventions based on ONS Guidelines™. FINDINGS: Patient (N = 73) symptom distress was quickly tracked, and there were no statistically significant changes in patient distress from admission to discharge, except for two symptoms.

Music Intervention: Nonpharmacologic Method to Reduce Pain and Anxiety in Adult Patients Undergoing Bone Marrow Procedures.

BACKGROUND: Bone marrow procedures cause anxiety and pain in adult patients with cancer. Music is a safe, inexpensive, noninvasive intervention that is easy to implement and is well received by patients and providers. OBJECTIVES: The purpose of this quality improvement project was to develop, implement, evaluate, and sustain a music protocol during bone marrow biopsy and aspiration procedures for adult patients with hematologic malignancies. In addition, this project sought to decrease pain, anxiety, heart rate, and blood pressure in patients undergoing bone marrow procedures. METHODS: The project coordinator collected baseline data regarding toleration of bone marrow procedures and then implemented a music protocol during the procedures during a six-month intervention phase. Comparison variables included pain, anxiety, heart rate, blood pressure, and subjective impressions. FINDINGS: The music protocol resulted in improved patient anxiety, decreased procedure time, and decreased medication use during bone marrow procedures. All patients who used the music intervention indicated they would use it again.

Larotrectinib: A Targeted Therapy for Solid Tumors.

BACKGROUND: Although neurotrophic tyrosine receptor kinase (NTRK) gene fusions are not common in most cancers, they are present in more than 90% of some rare tumors. The U.S. Food and Drug Administration has approved larotrectinib for patients with NTRK gene fusion-positive cancers that meet certain criteria. With ongoing advancements in tumor sequencing, it is anticipated that cancer treatment will be determined by genetic variants rather than by cancer type in the future. OBJECTIVES: This article provides an overview of larotrectinib, a targeted therapy. METHODS: This article reviews clinical trial results and highlights implications for oncology nurses caring for patients taking larotrectinib. FINDINGS: Larotrectinib is an effective treatment option for some patients with NTRK gene fusion-positive cancers. Oncology nurses are key to educating patients on dosing, administration, side effects, and precautions.

Low-Dose Computed Tomography: Effects of Oncology Nurse Navigation on Lung Cancer Screening.

BACKGROUND: Low-dose computed tomography (LDCT) lung cancer screening is an evidence-based and reimbursable strategy to decrease lung cancer and all-cause mortality in qualifying patients, but there remains low use and variation in providers' LDCT screening, ordering, and referring knowledge. OBJECTIVES: The purpose of this quality improvement project was to examine the effects of oncology nurse navigation on assisting patients and ensuring optimal LDCT lung cancer screening. METHODS: Oncology nurse navigators conducted LDCT provider education and navigated 133 eligible patients to LDCT during a five-month intervention time period. FINDINGS: Provider education resulted in improved documented tobacco cessation discussions and increased LDCT screening ordering fidelity. Mean days from LDCT to provider notification and mean days from LDCT to patient notification improved significantly.

Cancer Survivorship Program: Implementation for Individuals With Recurrent Breast Cancer.

BACKGROUND: Patients are living longer with recurrent breast cancer, but survivorship programs for these individuals are lacking. OBJECTIVES: The aims were to implement a survivorship program for individuals with recurrent breast cancer, increase their quality of life (QOL), and evaluate patient satisfaction with the program. METHODS: Survivors were referred for a one-hour coaching intervention tailored to their needs based on results of the Functional Assessment of Cancer Therapy-Breast (FACT-B) survey. Satisfaction was assessed immediately and two weeks postintervention. A paired t test was used to evaluate QOL scores before and two weeks following participation. FINDINGS: Statistically significant (p = 0.000) improvements were observed overall and in each subscale of the FACT-B survey. Patient satisfaction was high immediately postintervention and remained high at the two-week assessment.

Implementation of Survivorship Care Plans in Patients With Glioblastoma.

Background: The outcomes and survival of patients diagnosed with glioblastoma are improving due to advancements in therapy and better symptom management. Focusing on survivorship is an important initiative for these patients. A quality improvement project performed by an advanced practitioner in adults with glioblastoma evaluated the efficacy and utility of survivorship care plans (SCP). Providing patients and their families with SCPs gives them important information about their cancer, treatment, and follow-up management and care. Methods: Survivors of a glioblastoma who were receiving an oral alkylating agent and/or bevacizumab, as well as those who had completed these therapies within the past year were included. Patients had received surgery and radiation. The National Comprehensive Cancer Network (NCCN) Distress Thermometer and a pre- and postintervention survey evaluated knowledge, distress, and rate of follow-up care. Results: Over 2 months, 18 eligible participants received the SCP with a long-term care coaching appointment with an advanced practitioner. Knowledge pertaining to long-term effects of therapy and chemotherapy regimen improved. Ratings of overall distress and patient-reported primary care follow-up remained the same. Conclusion: Providing patients with glioblastoma with an SCP and an educational visit can improve knowledge pertaining to their chemotherapy regimens and long-term effects of therapy. This can result in more effective long-term management and care.

Preoperative Carbohydrate Loading in Patients Undergoing Thoracic Surgery: A Quality-Improvement Project.

PURPOSE: The purpose of this project was to implement carbohydrate loading in patients undergoing thoracic surgery in an effort to decrease postoperative pain, nausea, and length of stay as a part of an enhanced recovery after surgery protocol. DESIGN: This quality-improvement project used a preintervention and postintervention design. METHODS: Carbohydrate loading was given to 50 patients before undergoing thoracic surgery. Chart review was performed for 47 patients who received standard preoperative instructions in the preintervention group as historical control. FINDINGS: Patients who received carbohydrate loading had a decreased use of opioids in the first 4 hours after surgery (P = .028) and decreased use of antiemetic medication in the first 24 hours after surgery compared with the preintervention group (P = .066). Patients who were instructed to consume carbohydrate loading complied 87% of the time. CONCLUSIONS: Carbohydrate loading can decrease postoperative nausea and pain in patients undergoing thoracic surgery.

Optimizing Advanced Care Planning in Hospitalized Patients With Advanced Cancers: A Quality Improvement Initiative.

BACKGROUND: Advance care planning (ACP) that generates an advanced directive (AD) can ensure patient autonomy at end of life. ACP is challenging for healthcare providers. Delaying patient ACP may lead to poor quality end-of-life care. Facilitation of early ACP by bedside RNs and social workers (SWs) may improve end-of-life care. OBJECTIVE: To determine whether improved ACP by RNs and SWs impacts care transition times for patients with advanced cancers. METHODS: A pre-/post-educational intervention designed to reinforce the roles of RNs and SWs in facilitating early ACP and timely documentation of an AD on an inpatient oncology unit. RESULTS: AD documentation increased by 12% between pre- and post-intervention period. There was a nonsignificant trend toward longer lengths of stay for patients transitioning care without an AD compared to those patients with and AD. DISCUSSION: Bedside RNs and SWs are in a key position to facilitate early ACP which can positively impact care quality at end of life. However, ACP is a collaborative team effort, best initiated early by the primary oncology providers. CONCLUSION: Early ACP may improve quality end-of-life care. IMPLICATIONS FOR NURSING: Continuing education for RNs and SWs to enhance coordination with primary oncology teams to facilitate earlier ACP is recommended.

Pilot Study to Describe the Trajectory of Symptoms and Adaptive Strategies of Adults Living with Low-grade Glioma.

OBJECTIVES: To describe the adaptability to the patterns in symptoms and quality of life (QoL) during 6 months post low-grade glioma diagnosis by valid and reliable tools; to identify through qualitative interviews patient/provider adaptive techniques and strategies; and to assess associations among patient characteristics, symptoms and QoL, and adaptive techniques or strategies. DATA SOURCES: Demographic, clinical and pathologic data from medical records. Validated instruments that assess QoL, fatigue, depression, and distress were completed at 2, 4, and 6 months post diagnosis. Qualitative interviews identifying the symptoms, challenges, adaptive techniques and strategies were conducted at 4 and 6 months. CONCLUSION: The most frequently used adaptive strategies included: obtaining community support (87%), managing expectations (73%) and support systems (67%), and seeking out knowledge about physical (67%) and behavioral symptoms (53%). Seizures were reported with IDH1mut (11%) but not IDH1wildtype. Patients with either IDH1mut or TERTmut consistently reported lower QoL and higher distress, depression, and fatigue scores. IDH1/TERTmut may be related to lower QoL because of IDH1mut-related seizures. IMPLICATIONS FOR NURSING PRACTICE: Findings provide a list of adaptive strategies and characteristics to address the problems and symptoms that may improve overall QoL in patients with low-grade glioma.

Radiation Dermatitis: A Prevention Protocol for Patients With Breast Cancer.

BACKGROUND: Patients with breast cancer undergoing radiation therapy can experience dermatologic adverse events. Oncology nurses can advocate for radiation dermatitis (RD) prophylaxis to minimize dermatologic adverse events. OBJECTIVES: This quality improvement project was conducted to evaluate the effect of implementing an RD prevention protocol. The objectives of this study were to (a) improve clinicians' knowledge of screening, assessment, and prevention of RD in patients with breast cancer and (b) decrease the incidence of RD by 10% at a tertiary care cancer center. METHODS: Center-wide standards of care were created and implemented. A retrospective chart analysis was performed before and after protocol implementation. An education session was used to analyze protocol effectiveness. FINDINGS: Surveys completed by nurses (N = 11) before and after the education session demonstrated a significant increase in overall confidence in assessing RD. Statistically significant increases were noted in using topical steroids for prophylaxis.

Oncology Nurse Navigation: Development and Implementation of a Program at a Comprehensive Cancer Center
.

BACKGROUND: Oncology nurse navigation programs enhance coordination of care and patient satisfaction. 
. OBJECTIVES: The objective was to evaluate the effect of oncology nurse navigation on access to care, patient and provider satisfaction, and clinical trial enrollment of patients with hematologic or gynecologic malignancies.
. METHODS: A descriptive cohort study with a historic control was undertaken. Data were collected from electronic health records and patient and provider surveys in two disease-specific groups.
. FINDINGS: A significant decrease in the mean days from first provider visit to first therapy was observed in the hematology population. In both groups, time from contact to first visit and from first visit to initiation of treatment decreased. Mean satisfaction survey scores for both groups were high regarding relationships with the navigator and care received. Providers were highly satisfied with the program, and the navigation program did not increase clinical trials enrollment.

Influenza Adherence Tool Kit: Implementation and Evaluation Among Allogeneic Hematopoietic Transplantation Recipients
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BACKGROUND: Allogeneic transplantation is associated with significant complications, such as influenza, a common virus in the post-transplantation setting that can be detrimental to patients. Therefore, patients should adhere to influenza vaccinations.
. OBJECTIVES: The objectives of this project were to improve influenza adherence rates from 2015-2016, to increase transplantation recipients' knowledge of the importance of vaccination, and to evaluate the barriers to and facilitators of adherence rates to influenza vaccinations.
. METHODS: A pre-/postscreening survey was used, as well as a tool kit with an education pamphlet and financial incentive, and a reminder letter. 
. FINDINGS: Forty-eight eligible patients participated in the study, and 32 completed the prescreening questionnaire. The adherence rate for the 2015-2016 influenza season improved compared to the baseline vaccination rate. The findings revealed a strong association between provider recommendation and vaccination adherence.

Metastatic Lung Cancer and Distress: Use of the Distress Thermometer for Patient Assessment.

BACKGROUND: Patients with metastatic lung cancer experience high levels of distress related to their disease trajectory and treatment. Oncology nurses are experts in patient care and symptom management, giving them an opportunity to screen and treat patients' distress.
. OBJECTIVES: The objectives of this study were to screen patients for distress and manage their symptoms to positively affect their quality of life, treatment adherence, and clinical outcomes, and to reduce healthcare costs. 
. METHODS: This quality improvement project was conducted to pilot the Distress Thermometer (DT) into the care of patients with thoracic cancer and to evaluate the effect of a multifaceted intervention, consisting of a patient education pamphlet and a nurse coaching call, on distress levels. 
. FINDINGS: Severe distress was reported in more than half the patients. A paired-sample t test revealed a significant decrease in distress scores following the intervention.

Blinatumomab: A New Treatment for Adults With Relapsed Acute Lymphocytic Leukemia.

BACKGROUND: Patients with acute lymphocytic leukemia (ALL) often experience relapse of their disease following standard treatment. Blinatumomab (Blincyto®) is a newly approved option for inducing remission in individuals with relapsed or refractory Philadelphia chromosome-negative B-cell ALL. OBJECTIVES: This article provides an overview of blinatumomab, its benefits demonstrated in clinical trials, adverse effects, administration details, and the role of the oncology nurse in caring for and educating patients who receive blinatumomab. METHODS: This article summarizes the results of two phase II studies on blinatumomab and provides practice implications for nurses caring for patients receiving this therapy. FINDINGS: Attentive symptom monitoring and management are crucial. Individuals who achieve remission from blinatumomab can then be considered for stem cell transplantation and a chance for cure.

The Effects of a Take-Home Educational Video on Patient Knowledge Retention, Anxiety, Satisfaction, and Provider Time.

Patient anxiety related to prostate cancer surgery may lead to reduced patient satisfaction. Repeated reinforcement of pre-operative education to reduce anxiety greatly impacts provider time. Improved knowledge retention of what to expect postoperatively may reduce patient anxiety. This quality improvement project demonstrated that a take-home educational video supports patient knowledge retention, reduces patient anxiety, increases patient satisfaction, and saves postoperative provider time

A pilot study comparing the neutropenic diet to a non-neutropenic diet in the allogeneic hematopoietic stem cell transplantation population.

BACKGROUND: Historically, dietary restrictions imposed on patients undergoing hematopoietic stem cell transplantation (HSCT) were severe and limited to prevent exposure to foodborne organisms. With improvements in supportive care and anti-infective agents, the necessity of the neutropenic diet for this population has been in question. OBJECTIVES: This study aimed to determine whether the incidence of infection differs and to analyze the nutritional status in patients undergoing myeloablative allogeneic HSCT with a neutropenic diet as compared to those with a diet without restrictions. METHODS: This study was a randomized, controlled prospective pilot study beginning within the first 24 hours of the start of the conditioning regimen. Patients were randomized to receive a neutropenic diet or a diet without restrictions. All patients received care in a high-efficiency particulate air-filtered room on the inpatient adult blood and marrow transplantation unit (ABMTU). All patients received antibacterial and antifungal prophylaxis. Patients were followed until the end of neutropenia (defined as absolute neutrophil count of greater than 500 for three days) or until discharge from the inpatient ABMTU. FINDINGS: In 46 evaluable patients, no significant difference was found between infection rates or nutritional status. The neutropenic diet did not offer a protective effect against infection in patients undergoing myeloablative allogeneic HSCT. No differences were found in nutritional status between the two groups.

Ibrutinib: a new targeted therapy for hematologic cancers.

BACKGROUND: Hematologic cancers can occur from the overactivity of Bruton's tyrosine kinase, a proto-oncogene in blood cell maturation. Ibrutinib, a new oral targeted therapy drug, is the first agent that binds to the Bruton's tyrosine kinases and inhibits overgrowth of B cells. In blocking this overgrowth, ibrutinib has been shown to achieve lengthy remissions for patients with mantle cell lymphoma (MCL) and chronic lymphocytic leukemia (CLL). Remissions are highly valued in these cancers; cure is rare in MCL, and CLL is incurable. OBJECTIVES: This article reviews ibrutinib, its risks and benefits, and the role that oncology nurses play in educating patients and promoting drug adherence. METHODS: A comprehensive review of the literature was conducted using key words such as ibrutinib, mantle cell lymphoma, chronic lymphocytic leukemia, tyrosine kinase inhibitor, and oral chemotherapy. FINDINGS: Ibrutinib has been shown to be well tolerated, with manageable, low-grade toxicities compared to traditional cytotoxic agents. For all patients with a hematologic cancer, but particularly for the large proportion of older adults affected by hematologic malignancies, ibrutinib provides a new treatment option with a low toxicity profile.

A tailored nurse coaching intervention for oral chemotherapy adherence.

Although patients frequently express a preference for oral medications, compliance to these medications varies. Patients often have difficulty adhering to their medication schedules due to lack of understanding, inadequate support, or unwelcome side effects. Fostering adherence to oral chemotherapy regimens improves patients' chance of survival and long-term quality of life. This randomized trial tested the effectiveness of a tailored intervention to promote adherence to oral chemotherapeutic agents in 45 adult patients with cancer. The control group received the standard chemotherapy education provided at the cancer center. The intervention group received standard education and a tailored adherence plan developed by an advanced practice nurse. The nurse coaching intervention was administered via telephone. Adherence was measured using self-report and pharmacy refill rates. For adherence measures at both 2 and 4 months, the intervention group adherence rates were superior to the control group rates. Pharmacy refill rates of adherence were lower than self-reports. Results suggest that for some participants, the tailored coaching intervention was bene-ficial. Barriers to and facilitators of better adherence are discussed.

Adherence to antiemetic guidelines in patients with malignant glioma: a quality improvement project to translate evidence into practice.

PURPOSE: A quality improvement project was implemented to improve adherence to evidence-based antiemetic guidelines for malignant glioma patients treated with moderately emetic chemotherapy (MEC). Poorly controlled chemotherapy-induced nausea and vomiting (CINV) reduce cancer treatment efficacy and significantly impair cancer patients' quality of life (QOL). A review of Duke University Preston Robert Tisch Brain Tumor Center (PRTBTC)'s usual practice demonstrates a high incidence (45%) of CINV, despite premedication with short-acting 5-HT3-serotonin-receptor antagonists (5-HT3-RAs). National Comprehensive Cancer Network (NCCN)'s evidence-based guidelines recommend the combination of the long-acting 5-HT3-RA palonosetron (PAL) and dexamethasone (DEX) for the prevention of acute and delayed CINV with MEC. Low adherence (58%) to antiemetic guidelines may have explained our high CINV incidence. METHODS: One-sample binomial test, quasi-experimental design, evaluated a combination intervention that included a provider education session; implementation of risk-assessment tool with computerized, standardized antiemetic guideline order sets; and a monthly audit-feedback strategy. Post-implementation adherence to evidence-based antiemetic order sets and patient outcomes were measured and compared to baseline and historical data. Primary outcome was the guideline order set adherence rate. Secondary outcomes included nausea/vomiting rates and QOL. RESULTS: Adherence to ordering MEC guideline antiemetics increased significantly, from 58% to a sustained 90%, with associated improvement in nausea/vomiting. In acute and delayed phases, 75 and 84% of patients, respectively, did not experience CINV. There was no significant change in QOL. CONCLUSION: Combination intervention and audit-feedback strategy to translate evidence into oncology practice improved and sustained adherence to antiemetic guidelines. Adherence corresponded with effective nausea/vomiting control and preserved QOL in patients with malignant gliomas.