Category I: Patient Education

August 2014 Vol 5, No 4

Using a Financial Assistance Program as a Gateway to Support and Education for Underserved Breast Cancer Survivors

Catherine Creme Henry, MA; Arin Ahlum Hanson, MPH, CHES

Living Beyond Breast Cancer

Objectives: (1) To learn about Living Beyond Breast Cancer, (LBBC) regional grant program and its national education and support programs; (2) To understand the demographics served by LBBC’s grant program and identify their unique needs as breast cancer survivors; (3) To share innovative interventions to engage and support underserved breast cancer survivors that can be used by oncology nurse navigators.

Background: LBBC’s Cis B. Golder Quality of Life Grant assists with the financial burden of breast cancer treatment. Since 2006, the grant has funded more than 1100 women and helped pay bills such as rent/mortgage (53% of funds disbursed), utilities (34%), and childcare percentage. More than $1 million has been distributed in the Philadelphia area—90% of recipients earn less than 300% of the federal poverty line; 41% are African American; and 60% live in urban counties. A 2010 needs assessment indicated that recipients were not familiar with LBBC’s programs and had limited interactions with the organization. For many recipients, personal and financial crises made seeking information and support a low priority.

Methods: Interventions were developed to increase contact time with recipients and provide personalized invitations to other LBBC education and support programs. All applicants receive a peer support phone call from an LBBC Breast Cancer Helpline volunteer to share information about upcoming programs and refer them to resources to meet their needs. Special invitations are sent to recipients offering registration fee waivers to LBBC conferences and inviting them to tailored programs for low-income families.

Results: More than half (65%) of the applicants were previously unaware of LBBC and its support and education programs. All applicants receive 10 to 20 minutes of phone peer support and invitations to 2 local programs. Applicants receive several breast cancer publications on topics related to their concerns or experience. A nutrition-on-a-budget education series was piloted in 2013 to address recipients’ other wellness needs and provide meals. Fourteen women participated and reported that the program increased their knowledge of other nutrition resources available to them (70%), improved their confidence in cooking healthy meals (85%), and increased their likelihood of using other LBBC services (85%).

Conclusions: A financial assistance program provides a unique opportunity to engage underserved breast cancer survivors who may not otherwise seek support and education from an organization. The addition of peer support interventions helps assess and alleviate other concerns and connects recipients to a support system that they can access throughout their experience. Although LBBC’s financial assistance is regionally restricted, its interventions can act as a model for other grant programs.

Changes in Physical Activity Among Breast Cancer Patients Enrolled in a YMCA Program

Joan Giblin, NP; Carla J. Berg, PhD; Erin Stratton, MPH; Deborah W. Bruner, PhD; Andrew H. Miller, MD; Rebecca Gary, PhD

Living Beyond Breast Cancer

Little research has examined the promotion of community-based approaches to increase physical activity (PA) among cancer survivors, psychosocial factors predicating changes in PA, and the potential impact of increased PA on quality of life. Thus, the current study aimed to: (1) test the feasibility and acceptability of a coach-assisted, community-based exercise intervention at the Atlanta YMCA in Georgia targeting breast cancer survivors as well as its impact on PA; (2) examine psychosocial correlates of change in PA from baseline to week 24; and (3) determine the association between change in PA and quality of life among breast cancer survivors. We recruited 50 individuals diagnosed with breast cancer within 2 years of enrollment who were seen at the Winship Cancer Institute Cancer Survivorship Clinic. They were provided a 24-week membership to the YMCA and “The Coach Approach” program involving 3 prescribed exercise sessions each week. At baseline and week 24, we administered the Godin Leisure-Time Exercise Questionnaire, Patient Health Questionnaire-9 item, Multidimensional Fatigue Inventory, Multidimensional Scale of Perceived Social Support, and Functional Assessment of Cancer Therapy-General. Participants’ average age was 54.36 years (standard deviation [SD] = 10.65), 50% were white, 50% were black, and 58% had a bachelor’s degree or higher. Average time since treatment completion was 23.80 weeks (SD = 32.04). We achieved 80% retention at week 24. Overall, 58% had a record of meeting with a coach, with an average of 3.14 (SD = 1.56) meetings among those who never met with a coach. Additionally, 82% had a record of attending the YMCA for an exercise session with an average of 27.59 (SD = 25.77) exercise sessions among these participants. Those who attended the YMCA reported favorable process outcomes (eg, 97.2% reported they would recommend the program to other survivors). While there were no differences in change in PA from baseline to week 24 between those who had any record of attendance at the YMCA or who met with a coach versus those who did not (M = 3.75 [SD = 4.73] vs M = 5.50 [SD = 1.78], respectively; P = .472), there were significant increases in PA from baseline to week 24 among all participants (M = 3.66 [SD = 3.35] vs M = 7.59 [SD = 4.46]; P <.001). No baseline psychosocial measures predicted change in PA. Notably, change in PA was not correlated with changes in total quality of life or any subscale measure (physical, social, emotional, functional). In conclusion, breast cancer patients report increases in PA over time, potentially due to feeling better over time or due to messages given to them by their healthcare providers regarding the importance of PA for cancer survivors. This pilot study has limitations that should be addressed in future research to examine these associations in larger samples over longer periods of time.

Preadmission Stem Cell Transplant Teaching: A Team Approach

Tina Scherer, RN, MSN, OCN

Helen F. Graham Cancer Center, Christiana Care Health System

The Hematology Stem Cell Transplant Education Team addresses the educational and psychosocial needs of transplant patients in a multidisciplinary fashion. Central to this formal education plan is the unique partnership of the Oncology Certified RN Hematology Navigator and Health Psychologist who assess these needs throughout the continuum of care. The process centers around a customized patient/caregiver educational meeting at which time comprehensive participative needs assessment and psychosocial evaluation are completed, goals are developed, and interventions are initiated and brought to discussion with the entire Stem Cell Transplant Team.

Because of the complexity of the transplant process, adequate tailored patient and caregiver education is crucial. Our purpose is to perform a coordinated assessment process to identify immediate and future educational and psychosocial needs and to develop an educational plan to foster patient/caregiver empowerment. This educational program results in a better understanding and compliance with treatment plan recommendations.

The need for earlier referrals to the Nurse Navigator and Psychologist team was recognized, and the weekly multidisciplinary bone marrow transplant meeting serves as this initial referral. Now the treatment plan is completed collaboratively by the entire transplant team. This plan provides initial insight into the educational and psychosocial needs of the patient/caregiver.

Prior to the patient/caregiver meeting, an educational binder is individualized based on transplant type. This binder guide provides the written materials necessary to satisfy alternative learning styles. A needs assessment to investigate knowledge, financial, and psychosocial issues of the patient/caregiver is performed, and an exclusive teaching plan is immediately initiated.

After the meeting, referrals are made to ancillary support services and community agencies for continued assistance, assessment, and education.

We have found our up-front assessment and screening followed by individual instruction has attained a more successful learning experience. Our patients have verbalized a marked decrease in anxiety and increase in knowledge, which has facilitated better compliance with the treatment plan. Based on assessment of knowledge and understanding, the physicians concur upon signing the informed consent.

This project stresses the importance of the nurse’s role in patient education, which can be duplicated in various practice settings.

Adjuvant Treatment with Toremifene in Hormone Receptor–Positive Breast Cancer: A Systematic Review of the Literature

Carolyn Lavender, MSN, AOCNP, ARNP1; Deborah Braccia, PhD, MPA, RN1; Marcelle Kaplan, RN, MS, AOCN, CBCN2; Fiona M Herr, PhD3

1ProStrakan, Inc; 2Adelphi University; 3Aranmore Medical Communications

Objective: To review all published data on the efficacy and safety of toremifene use in the adjuvant treatment of hormone receptor–positive breast cancer. Significance: Endocrine therapy is an integral part of the backbone for hormone receptor– positive breast cancer treatment. Toremifene and tamoxifen are approved for hormone receptor–positive metastatic breast cancer. Tamoxifen is also approved for use in adjuvant breast cancer; however, tamoxifen may not be appropriate for all patients. Therefore, alternatives to tamoxifen in the adjuvant setting should be explored.

Purpose: To review and assess all available data on the efficacy and safety of toremifene in the adjuvant treatment setting.

Methods: Systematic review of PubMed using the search terms “toremifene and adjuvant,” “Fareston and adjuvant,” “tor­emifene and early breast,” or “Fareston and early breast.”

Results: Five published prospective trials, 2 retrospective trials, and 2 meta-analyses examining the use of toremifene versus tamoxifen in the adjuvant setting were identified. Combined, the 5 prospective trials gave toremifene (40 or 60 mg) to 1557 women compared with tamoxifen (20 mg) to 1533 women for 2 to 5 years. A combined analysis of 1035 women enrolled in 2 different trials showed similar disease-free survival (DFS), overall survival (OS), and recurrence rates after a mean 5.5 years of follow-up. A separate study showed similar time to recurrence, risk of recurrence, and OS rates with 3 years of therapy with tamoxifen or toremifene. Another study in patients with 5 years of toremifene therapy demonstrated equivalent OS with a median follow-up of 59 months. A recent phase 3 prospective study in postmenopausal women reported noninferiority of adjuvant treatment with toremifene compared with tamoxifen. Both treatments were safe and well tolerated, with no significant differences in the frequency or severity of adverse events in each of these adjuvant trials. A retrospective study in premenopausal women examined records from 452 patients and showed similar OS with improved DFS with adjuvant toremifene compared with tamoxifen. A second retrospective study with 1847 patients found similar efficacy results. Finally, 2 recent meta-analyses involving more than 3700 patients both reported similar OS, DFS, and safety in patients given adjuvant tamoxifen or toremifene.

Discussion: A series of published studies indicate toremifene is as effective and safe as tamoxifen in the adjuvant setting.

Differences in Metabolite Activity of the Selective Estrogen Receptor Modulators Tamoxifen and Toremifene: Clinical Implications for Patients with Hormone Receptor–Positive Breast Cancer

Marcelle Kaplan, RN, MS, AOCN, CBCN1; Carolyn Lavender, MSN, AOCNP, ARNP2; Deborah Braccia, PhD, MPA, RN2

1Adelphi University; 2ProStrakan, Inc

Objective: To review published data on the metabolism of toremifene and assess any implications for treatment decisions.

Significance: The use of selective estrogen receptor modulators (SERMs) forms part of the treatment backbone of hormone receptor–positive breast cancer. Studies have shown that tamoxifen and toremifene, the 2 SERMs approved for the treatment of hormone receptor–positive breast cancer, have similar efficacy and safety profiles. Although tamoxifen metabolism has been extensively studied, there has been limited information regarding toremifene metabolism and any potential implications for practice.

Purpose: To review recent data on the metabolism of toremifene as well as significant drug–drug interactions that may impact treatment decisions.

Methods: A literature review of PubMed was conducted using the search terms “toremifene,” “metabolism,” “Fareston,” “cytochrome P450,” and “CYP2D6.” Results: Toremifene is thought to be active in its parent form, and is mainly metabolized in the liver by cytochrome (CY) P3A4. In contrast, tamoxifen requires metabolism by CYP2D6 to be converted to its biologically active 4-hydroxyl metabolites. Data suggest that potent CYP2D6 inhibitors, such as certain selective serotonin reuptake inhibitors (SSRIs), can result in alterations in plasma concentrations of the 4-hydroxyl metabolites of tamoxifen. Although published studies on the use of SSRIs and outcome of adjuvant therapy with tamoxifen remain discordant, National Comprehensive Cancer Network guidelines currently recommend against coadministration of strong inhibitors of CYP2D6 and tamoxifen. A series of recent studies directly compared the metabolic activity of toremifene and tamoxifen in human liver microsomes and showed that metabolism of toremifene was unaffected by the presence of potent CYP2D6 inhibitors or by CYP2D6 genetic status. However, metabolism of tamoxifen was significantly altered by CYP2D6 inhibitors and CYP2D6 genetic status. Concentrations of the active form of toremifene were unaffected by SSRIs or the potential variation in CYP2D6 genetic status.

Discussion: Although variations in CYP2D6 metabolic activity cause differences in plasma concentrations of active tamoxifen metabolites, the debate regarding the clinical sequelae of the CYP2D6 alterations and outcomes in patients taking tamoxifen is ongoing. Potential drug–drug interactions with SSRIs may alter the efficacy of tamoxifen and thereby inform treatment choices. Toremifene is unaffected by coadministration with SSRIs and represents a well-studied SERM option for treating patients with estrogen-positive breast cancer where CYP2D6 inhibition may be of concern.

Risk of Chemotherapy-Induced Anemia Among Patients Diagnosed with Lung Cancer

Hairong Xu, MD, PhD1; Lanfang Xu, MSc2; John H. Page, MD, MSc, ScD1; Olivia Sattayapiwat, MSc2; Roberto Rodriguez, MD3; Chun Chao, PhD2

1Amgen Inc; 2Kaiser Permanente Southern California; 3Los Angeles Medical Center, Kaiser Permanente Southern California

Introduction: Anemia is a common complication of chemotherapy that can cause clinically important symptoms and reduced quality of life. Yet, little data exist on the burden of chemotherapy-induced anemia (CIA) in current oncology practice.

Objective: To estimate the incidence and severity of CIA in patients with lung cancer receiving chemotherapy.

Methods: Patients diagnosed with incident lung cancer who received chemotherapy were identified from the Kaiser Permanente Southern California Health Plan (2010-2012). Patients who had anemia before chemotherapy (ie, diagnosis of inherited anemia or hemoglobin [Hb] measurement <10 g/dL within 3 months prior to chemotherapy initiation) were excluded. All clinical data were collected from electronic medical records. Anemia was classified by severity (grade I: 10 g/dL to lower limit of normal; grade II: 8.0-9.9 g/dL; grade III: 6.5-7.9 g/dL; grade IV: <6.5 g/dL). Incidence proportions of patients developing CIA were calculated overall and by CIA severity and morphologic type, as well as by stage at cancer diagnosis, chemotherapy regimen, and cycle.

Results: A total of 888 patients with lung cancer who received chemotherapy were included. The mean age was 67 years. The stage distribution was 4.5% stage I, 9.2% stage II, 27.8% stage III, and 58.5% stage IV. The most frequent regimens were carboplatin plus paclitaxel (34.1%), carboplatin plus etoposide (23.5%), and pemetrexed plus cisplatin/carboplatin (18.2%). A total of 827 patients (incidence proportion 93%; 95% confidence interval, 91%-95%) developed anemia during the first course of chemotherapy (51% grade I, 35% grade II, 12% grade III, and <2% grade IV; normocytic 84%, macrocytic 11%, microcytic 4%, normochromic 43%, hyperchromic 50%, hypochromic 7%). The risk of moderate-to-severe anemia (grades II-IV, Hb <10 g/dL) is 48% in stage IV disease compared with 35% in stage I. The incidence of severe anemia (grades III-IV, Hb <8 g/dL) is approximately 14% in patients with stage IV disease.

Conclusions: The risk of moderate-to-severe CIA (Hb <10 g/dL) is approximately 45% overall in patients with lung cancer receiving chemotherapy, and this risk is greater in patients with distant metastasis. The risk of severe anemia (Hb <8 g/dL) is more than 10% in patients with lung cancer receiving chemotherapy.

Efficacy of a Transdermal Granisetron Patch in Controlling Chemotherapy-Induced Nausea and Vomiting in Patients with Head and Neck Cancer

Doru Paul, MD

Monter Cancer Center–NorthShore-LIJ Health Systems

Objective: To examine the efficacy of a transdermal granisetron patch for controlling chemotherapy-induced nausea and vomiting (CINV) in patients with head and neck cancer.

Significance: Patients with head and neck cancer can experience mechanical obstruction or dysphagia, making adherence to oral medications, including common oral antiemetics, very difficult. A granisetron transdermal system (GTS) has been shown to be as effective as oral granisetron in controlling CINV across multiple tumor types. This post hoc analysis specifically examined the efficacy and safety of GTS in difficult-to-treat patients with head and neck cancer.

Purpose: To compare the rates of complete control (CC; no vomiting, mild nausea, no rescue medication), complete response (CR; no vomiting, no rescue medication), need for rescue medication, and patient-reported assessment in patients with head and neck cancer using either GTS or oral granisetron.

Methods: A randomized, phase 3 study has been published comparing GTS (7-day application) to oral granisetron (2 mg/day) in patients receiving either moderately or highly emetogenic chemotherapy for 3 to 5 days. Data for this analysis were limited to patients with head and neck primary tumors.

Results: Seventy-one patients (38 GTS, 33 oral granisetron) were included. The CC rate of 66% and CR rate of 68% in the GTS group were similar to rates in the overall population. There was no difference in CC, CR, and use of rescue medication between GTS and oral granisetron (P = .94, P = .91, and P = .57, respectively). Patient assessment of overall response to therapy was not different between arms (P = .26). GTS was well tolerated and treatment-related adverse events were mild.

Discussion: This retrospective analysis suggests GTS may be an appropriate option for prevention of CINV in patients with head and neck cancer at high risk of dysphagia treated with chemotherapy.

Nursing Roles in Coordinating an Efficient Workflow for Radium-223 Dichloride (Ra-223) Administration

Gabrielle Arauz, RN, BSN, OCN1; Tara Kilkenny, RN, BSN, OCN1; Anne-Kirsti Aksnes, MSc, PhD2; Mona Wahba, MD, MSM3; Tracy Curley, RN, OCN1

1Memorial Sloan Kettering Cancer Center; 2Algeta ASA (Bayer); 3Bayer HealthCare

Background: Radium-223 dichloride (Ra-223), a first-in-class alpha-emitting radiopharmaceutical that selectively targets bone metastases (mets) with high-energy, short-range (2-10 cell diameters) alpha particles, is approved for the treatment of patients with castration-resistant prostate cancer (CRPC) with symptomatic bone mets and no visceral metastatic disease. Administering Ra-223 involves a multidisciplinary team, including nurses who are vital in coordinating patient care and facilitating efficient workflow throughout Ra-223 treatment.

Objectives: Essential to the success of an interdisciplinary therapy, such as Ra-223, is a clearly defined workflow to help patients navigate the cancer care continuum. Nurses play critical roles in educating patients and coordinating care across clinical disciplines. Here we present phase 3 ALSYMPCA trial efficacy and safety data that support using Ra-223 in patients with CRPC, along with key information on the multidisciplinary teams involved in Ra-223 administration, to help guide nurses in facilitating effective workflow.

Methods: In ALSYMPCA, eligible patients had progressive, symptomatic CRPC with ?2 bone mets and no known visceral mets; were receiving best standard of care; and had either previously received, were unfit to receive, or declined docetaxel. Patients were randomized 2:1 to 6 intravenous injections of Ra-223 (50 kBq/kg every 4 weeks; n = 614) or placebo (n = 307). The primary end point was overall survival (OS); secondary end points included symptomatic skeletal events (SSEs) and safety.

Results: Ra-223 significantly improved OS (median, 14.9 vs 11.3 months; hazard ratio [HR] = 0.70; 95% confidence interval [CI], 0.58-0.83) and delayed time to first SSE (median, 15.6 vs 9.8 months; HR = 0.66; 95% CI, 0.52-0.83) versus placebo in patients with CRPC with symptomatic bone mets. Ra-223 also had a favorable safety profile with mild gastrointestinal events and a low incidence of myelosuppression. Successful Ra-223 administration depends on patient education (eg, importance of completing all 6 cycles, side effects, managing expectations of symptom improvement) and efficient workflow across departments. Responsibility for insurance verification, administration, and symptom management can vary greatly, depending on the institution. Nurses play a significant role in coordination between disciplines and are fundamental in maintaining a well-defined process for managing these patients to ensure optimal care.

Conclusions: Ra-223 is a well-tolerated, effective, easily administered treatment for patients with CRPC and symptomatic bone mets. Nurses are essential members of the oncology team, providing patients with education and guidance about Ra-223; they are integral in coordinating patient care throughout treatment and ensuring efficiency across multidisciplinary teams.

Nurses as Scribes: A New Role for the Oncology Nurse Navigator

Lisa Bruno, RN BSN, OCN; Peggy Malone, RN, BS, OCN

OSF Saint Anthony Center for Cancer Care

Background: Being adequately prepared for an experience such as cancer empowers the patient as well as improves self-management and quality of life.1 The first visit with the oncologist can be extremely overwhelming and anxiety-producing. Oncology nurse navigators need an effective way to communicate the information that is discussed during the initial oncology physician consultation to newly diagnosed cancer patients and their families. A documentation template was developed so the oncology nurse navigators could take notes while accompanying patients and families during the initial visit with the oncologist.

Objective: To help patients and families better understand all the information that is presented in the initial consult with the medical oncologist.

Methods: A 1-page form was developed that included headings for the following: type of cancer, stage of cancer, details of cancer, test results, medications prescribed, chemotherapy planned, name of chemotherapy and how often it will be given, radiation therapy planned, and an area on the form labeled “What’s next?” to aid the patient in understanding the next steps to take in the cancer care process. Two separate documentation templates were developed for both medical oncology and radiation oncology consults. This form can also be utilized as a teaching tool to summarize the important information covered in the visit before the patient leaves utilizing the “teach-back” method.

Results: The oncology nurse navigators now consistently use this “Summary of Visit” form to provide a written summary of everything discussed with patients during their initial oncology consultation, and a copy is provided to the patient before leaving the clinic. The nurse acts as a scribe for the patient and families, ensuring that all the pertinent information discussed at the visit is recorded.

Conclusions: Patients and families verbalized that having access to the information provided by the oncologist from the initial consult enhanced comprehension and supported communication regarding disease stage, treatment plan, and referral information. They also commented that they were better able to focus on details of the oncologist’s interactions knowing they did not need to take notes themselves. The use of this “Summary of Visit” form has enhanced the readiness of patients for treatment and improved communication between the patient and the oncology team members. The next steps include: (1) creating an electronic version of the templates that can be entered directly into the electronic medical record at the time of the visit, which would allow other practitioners access to the information; and (2) incorporating the “Summary of Visit” note into OSF myHealth functionality, which allows the patient online access to some of his or her medical record information.

1. Knobf MT. Being prepared: essential to self-care and quality of life for the person with cancer. Clin J Oncol Nurs. 2013;17(3):255-261.

Using a National Needs Assessment to Direct Programs for Young Women Affected by Breast Cancer

Arin Ahlum Hanson, MPH, CHES; Janine Guglielmino, MA; Catherine Creme Henry, MA; Kimlin Ashing, PhD

Living Beyond Breast Cancer

Introduction: Ten percent of breast cancer cases occur in women under age 45 years. Although younger women are less likely than older women to be diagnosed, their survivorship needs can differ, making breast cancer a significant public health concern for this age group. To address this need, Living Beyond Breast Cancer (LBBC) developed new national programming for young women, after conducting a comprehensive needs assessment and selecting program priorities based on assessment findings. This project was funded through a cooperative agreement with the Centers for Disease Control and Prevention.

Methods: LBBC identified the needs of women diagnosed with breast cancer before age 45 years and determined how young women prefer to receive emotional support and breast cancer information. Needs assessment phases were (1) an environmental scan to identify existing resources; (2) key informant interviews with 12 healthcare providers; (3) 4 focus groups with 32 women; and (4) an 85-question national online survey completed by 1474 women diagnosed with breast cancer before age 45 years. LBBC analyzed findings by stage, ethnicity, age, and time since diagnosis, setting program priorities based on these findings.

Results: The needs assessment findings led LBBC to create online resources for young women, expand the Breast Cancer Helpline, develop a Young Advocate Program, and educate healthcare providers about the needs of young women. In addition, LBBC expanded resources for women diagnosed before age 30 years, young women living with metastatic breast cancer, and young African American women who reported different needs for and interests in health information.

Conclusion/Implications: LBBC successfully expanded its program offerings to better serve young women. Preliminary evaluation data show LBBC’s new programs are increasing knowledge and support. This process demonstrates the benefits of using needs assessments to drive program development. This model can be used for other cancer survivor populations, where knowledge of their needs and program offerings are lacking.

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Last modified: April 9, 2021

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