Living with advanced cancer and the role of the primary care provider: The missing piece in the survivorship discourse.

The period of survivorship has been identified as a distinct phase of the cancer continuum, and the key role of primary care providers in caring for cancer survivors has been recognized. However, much of the focus to date has been placed on cancer survivors who are treated with curative intent and survive cancer-free. Receiving less attention are those who are living with advanced, non-curative cancer. In this commentary, we review the current evidence about the characteristics of these survivors, their unmet needs and receipt of health care. We offer insights into future research, education and policy initiatives aiming to enhance the care for this population.

Is there a role for survivorship care plans in advanced cancer?

PURPOSE: The Institute of Medicine (2006) has recommended that cancer survivors completing treatment receive a survivorship care plan (SCP). The survivorship needs in advanced cancer have been overlooked and understudied. The potential role of SCPs for survivors with advanced or metastatic cancer is unknown and was explored in this study. METHODS: We conducted two focus groups of survivors with advanced or metastatic cancer. Participants reviewed a sample JourneyForward™ SCP modified for advanced cancer. Sessions were audiotaped and transcribed; transcripts and field notes were evaluated using inductive content analysis. RESULTS: Sixteen survivors with metastatic cancer participated: 12 (75 %) were female, 15 (94 %) were white, and median age was 66 (range 55-80); 9 participants had breast cancer, 4 colon, 2 prostate, and 1 ovarian cancer. Participants believed that an SCP would be most helpful after initial diagnosis and treatment, but not as helpful once the cancer progressed. They thought a "cancer care plan" focusing solely on the current management would be better to concisely summarize the treatment plan and time frame for the next segment of care for those with advanced cancer. Most participants endorsed the need to have written information to reinforce verbal information received during medical visits since it was difficult to remember information provided. Participants expected their oncologist to assume primary responsibility for coordination of the care plan, but anticipated an important supportive role for primary care providers. To this end, they emphasized the need for better communication between providers. CONCLUSIONS: A cancer care plan developed by the oncologist, similar to an SCP but more focused on current management, may be more useful for survivors with advanced cancer. Exploring this topic in larger groups of more diverse survivors with advanced cancer will help to elucidate the details a written plan of care should contain, and how to promote effective coordination between oncology and primary care providers. IMPLICATIONS FOR CANCER SURVIVORS: There are many transitions of care along the cancer journey. A written plan of care, similar to an SCP, may be useful for survivors with advanced cancer.

Balancing efficacy with cost: antiemetic control in the pediatric stem cell transplant (SCT) population.

We studied the practice patterns regarding intravenous (i.v.) ondansetron in children receiving stem cell transplants (SCT) at The Children's Hospital, Boston to identify cost efficiencies. The pharmacy provided information on material and preparation costs on 36 patients who received i.v. ondansetron during 41 SCT in 1995. We examined the effects of frequency, duration, and route of administration on costs. There were 498 days of ondansetron administration costing $49,083 (95$). Tremendous variation existed in frequency and duration with one third receiving i.v. ondansetron once daily, despite published evidence of equivalence of once a day and divided dosing. A switch to once daily i.v. dosing for all patients would have resulted in >/=28% savings. The median duration of use was 11 days (range 1-48); placing a cap for 7-10 days based on the length of SCT conditioning regimens, would produce savings of 48-60% over current use. By shifting administration route from i.v. to oral, a savings of 67% over current use, without a cap on duration, would be realized. Identifying areas for cost savings can be achieved after thorough analysis of all the component costs. We demonstrated that significant cost reductions could be realized by simple changes in prescribing practices without jeopardizing efficacy. These savings are achieved by standardizing dosing interval, route of administration and duration of treatment without altering daily dosage or access to an effective antiemetic. Bone Marrow Transplantation (2000) 25, 553-557.

Prevention, early detection, and management of oncologic emergencies.

The prevention and early detection of oncologic emergencies is critical in caring for the person with cancer. Although many will not develop an oncologic emergency during the course of their illness, the approach outlined in this paper will contribute significantly to the prevention and relief of suffering in those individuals who may develop them.

Information for women: management of menopausal symptoms.

PURPOSE/OBJECTIVES: To provide a written reference for women experiencing menopause-related symptoms. DATA SOURCES: Professional and popular books and articles. DATA SYNTHESIS: The process and symptoms of menopause are described in simple terms. Hormone replacement therapy is presented in terms of benefits and risks. CONCLUSIONS: A booklet is an easy-to-produce, efficient strategy for addressing common patient concerns. IMPLICATIONS FOR NURSING PRACTICE: A written booklet can assist nurses in presenting the necessary information to women experiencing or at risk for experiencing symptoms of menopause and in counseling them about potential interventions.

Article on breast cancer risk and induced abortion concerns readers.

PIP: Inappropriate and inaccurate counseling with regard to abortion and the risk of breast cancer may result if readers accept without critical review Lucille Canty's biased article on the association between induced abortion and breast cancer printed in Oncology Nursing Forum (ONF). The potential resulting psychological harm could be considerable. The current debate over whether women have increased risk of developing breast cancer after an induced abortion continues, and the findings produced thus far have been inconclusive. Many scientists, including researchers at the National Cancer Institute, do not agree that any connection exists between induced abortion and breast cancer. Considering the complexity of assessing risk, a more thorough discussion of methodologic issues when assessing risk would have better served ONF readers. Furthermore, a less biased approach would have presented each of the studies more objectively. Finally, the conclusions which Canty drew in her abstract and article did not reflect the relative risks and conclusions drawn in the current literature she cited on the subject in her text.^ieng

The future of advanced clinical practice in oncology nursing.

Futures research, a popular field that forecasts the future based on past and present statistics and trends, can help oncology nurses project needs and prepare for the unknown. Projections based on past and present statistics and trends related to health care, nursing, and cancer abound. They provide some guidance but fall short of describing how nurses can best respond to the growing number of patients with cancer, survivors of cancer, their families, and communities. If we can define, measure, and articulate the effect that advanced practice nurses have on patients with cancer, we can determine the most effective way to implement cancer care in the future.

Overcoming multidrug resistance: valspodar as a paradigm for nursing care.

PURPOSE/OBJECTIVES: To review the mechanisms of multidrug resistance (MDR) in human cancer and the clinical use of MDR modulators to overcome or reverse P-glycoprotein (P-gp)-mediated MDR. DATA SOURCES: Current literature, ongoing clinical trials, and clinical experience. DATA SYNTHESIS: Agents, such as valspodar, that block the activity of P-gp can reverse or overcome MDR caused by overexpression of P-gp. The MDR modulator valspodar (PSC 833; Novartis Pharmaceuticals Corporation, East Hanover, NJ) is examined as a model for establishing nursing guidelines for this new class of therapeutic agents. CONCLUSIONS: The dose of some chemotherapy agents must be modified with concurrent valspodar administration. Studies examining the safety and efficacy of valspodar as a prototype of MDR modulators provide the basis for establishing nursing care guidelines. IMPLICATIONS FOR NURSING PRACTICE: Nursing care for the administration of valspodar includes understanding patient selection, criteria, dosing, and administration; side-effect management; patient monitoring and follow-up; and patient education.

Bone metastases: Part I--Pathophysiology.

Many cancers (especially breast, prostate, and lung cancers) metastasize to the bone. The most frequent site of bone involvement is the axial skeleton (i.e., cranium, ribs, spine, and pelvis). The sequelae of bone metastases include pain, hypercalcemia, pathologic fractures, and spinal cord compression. As patients survive for longer periods, effective management of bone metastases becomes critical to maintaining or improving quality of life. Controlling pain, preventing fractures and oncologic emergencies, and promoting mobility and function are the outcomes of successful management. Use of a clinical algorithm can assist the nurse in identifying bone metastases and managing the clinical sequelae. Knowledge of the pathophysiology and the ability to assess bone metastases will contribute to the nurse's ability to manage the clinical problems and to improve the quality of life of patients with cancer.

Bone metastases: Part II--Nursing management.

Nurses play a crucial role in identifying bone metastases and managing clinical sequelae, such as pain. Understanding the metastatic process is necessary for delivering effective nursing care. Part I of this article described the pathophysiology and assessment. Part II will provide an overview of the nursing management of the sequelae of bone metastases, including pain, pathologic fractures, spinal cord compression, hypercalcemia, and anemia. Risk factor identification can lead to prevention and early detection of these clinically significant problems. Clinical management of bone metastases will contribute to the nurse's ability to improve the quality of life of patients with cancer.

Perspectives on cancer patient education.

OBJECTIVES: To provide an overview on cancer patient education. DATA SOURCES: Literature related to demographic and health care trends, patient education, health literacy, and cancer patient information needs. CONCLUSIONS: Cancer patients need information related to diagnosis, treatment, side effects, self-care needs, and effects on work and relationships. Planned patient teaching includes a variety of teaching strategies and written materials, and contributes to better patient outcomes. Inadequate health literacy and other barriers present challenges to providing effective patient education. IMPLICATIONS FOR NURSING PRACTICE: More research is warranted in developing assessment tools and effective health education techniques and in measuring outcomes and costs related to patient education. The education needs of cancer patients will not drastically change in the next century. How nurses meet those needs, however, will change as we apply new learning theories and technologies of teaching.

Obstacles to implementing cancer clinical trials.

There are numerous obstacles to implementing and conducting clinical trials. Patient accrual and the costs of clinical trials are difficult problems for researchers. Additional obstacles to implementing clinical trials are patient-related, physician-related, and nurse-related barriers.

Biotherapy: recent advances and nursing implications.

Nurses have and will continue to play a crucial role in the development and application of new BRM agents and products. Joint ventures between the National Cancer Institute, traditional academic centers, and private industry have produced new partnerships expanding the number and types of biologic research studies being conducted in various patient care settings. Nursing's contributions in these new ventures are significant and ongoing. If not directly involved in studying and administering BRM agents, the nurse will be involved in the education and counseling of persons who may participate in this new cancer treatment modality. Nurses will need to be familiar with BRM because many people will query them about this new field. Dr. Ehrlich concluded his address in 1900 by stating: "We no longer find ourselves lost on a boundless sea, but that we have already caught a distinct glimpse of the land which we hope, nay, which we expect, will yield rich treasures for biology and therapeutics." Are we there yet?

Diagnosis and management of intestinal obstruction in individuals with cancer.

Small bowel obstructions, which account for two-thirds of all intestinal obstruction, are caused by adhesions, hernias and cancer. Large bowel obstructions are usually the result of a malignancy, but may also be caused by diverticulitis or volvulus. Previously treated individuals with a known diagnosis of advanced cancer originating in the pelvis are at highest risk for developing intestinal bowel obstruction. Since 30 percent of Americans will develop cancer in their lifetimes, and colorectal cancer is the most common type, this represents a significant population at risk to be followed by nurse practitioners. The pathophysiology, assessment and management of an individual with a bowel obstruction is reviewed. Morbidity and mortality in this population is high. Wound healing problems, including infection, dehiscence, evisceration and fistula formation, contribute significantly to the morbidity and can cause long-term problems. In today's health care system, it's likely that patients will be discharged from the hospital earlier after bowel surgeries. Therefore, nursing care focusing on wound management is outlined.