	Preoperative chemotherapy was not a predictor of postoperative complications, nor did it increase the length of hospital stays or surgical complications among patients undergoing radical cystectomy for muscle-invasive bladder cancer.

	Yet the use of platinum-based multiagent neoadjuvant chemotherapy (NAC) in radical cystectomy patients was “strikingly low” in a retrospective analysis of data from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP).*

 These data mirror results from other studies detailing underuse of a safe, guidelines-recommended treatment strategy that is also associated with a survival advantage.

	David Johnson, MD, reported these findings on behalf of a group of researchers from the University of North Carolina, Chapel Hill during the Annual Meeting of the Southeastern Section of the American Urological Association.

	The ACS-NSQIP Participant Use Data File spans the years 2005-2011 and includes data on 135 variables, including perioperative information, 30-day postoperative complications, and mortality at the contributing institutions. During that time period, in this analysis of 878 patients who underwent radical cystectomy, a total of 457 patients (52%) experienced at least one complication within 30 days after surgery, Johnson et al reported.

	The investigators found that NAC did not significantly increase the morbidity associated with radical cystectomy. Their analysis revealed no significant differences in postoperative complication rates and no increase in operative time associated with the use of NAC. Further, NAC was a significant predictor of shorter length of hospital stay by multivariate analysis, when adjusting for significant predictors of length of stay such as age, race, year of operation, functional status, and operative time (

	“Our study basically takes a large dataset that includes both academic and community hospitals and looks at a nationwide picture of utilization of neoadjuvant chemotherapy. What it shows is that the utilization rate is still quite low even though there is an unequivocal survival benefit,” Johnson said. In a meta-analysis and a later update of that study that included 3005 patients from 11 randomized trials, NAC demonstrated an approximately 5% increase in 5-year overall survival.

	Only 8.9% of patients who underwent radical cystectomy from 2005 to 2011 and were included in the Johnson et al study received NAC. This low NAC use rate was not explained by excluding patients for whom treatment with chemotherapy would be a health risk: only seven patients had preoperative renal failure, a potential contraindication, Johnson explained.

	“We know that we have not been able to affect survival just by improvements in surgical techniques and detection and diagnostic techniques,” he said. “That leads us to believe that we need something more to treat it as a systemic disease. The problem is that it has not been widely implemented.”

	Why is this? Two recent reviews of data on the underuse of chemotherapy in the setting of bladder cancer concluded that the utilization of neoadjuvant chemotherapy is attributable to the choice of patients and/or physicians based on factors that can include advanced patient age, patient comorbidities such as renal and/or cardiac dysfunction, and a perception of limited benefit.

			Figure. Bivariable Analysis: Overall Complications: 457/878 (52%)

			NAC indicates neoadjuvant chemotherapy.

	In some instances, patients and physicians may not want to delay surgery. Or, they are uncomfortable about the potential toxicities of neoadjuvant chemotherapy. (There is a high overall complication rate with chemotherapy, although it is higher with adjuvant than with neoadjuvant administration.)

	Some patients, Johnson said, may think that “a 5% survival benefit is not worth going through 3 months of chemotherapy.” Or, physicians/ surgeons may demur because they are not familiar with or do not believe the data, or they themselves do not think the 5% survival benefit is worth putting the patient through the chemotherapy.

	Experience with the regimen and a multidisciplinary team setting may contribute to greater use of neoadjuvant therapy in bladder cancer. At the University of North Carolina, as with other high-volume cancer centers, Johnson said, treatment decisions are made within multidisciplinary clinics where the patient is a team member.

	“That is what we do at UNC to promote appropriate use of neoadjuvant chemotherapy,” he said, “and it may be one of the best ways of doing it.”

*The ACS NSQIP and the hospitals participating in the ACS NSQIP are the source of the data used herein. They have not been verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

				Johnson D, Kirby W, Ferguson J, et al. Utilization of preoperative chemotherapy and associated outcomes after radical cystectomy: an analysis of the American College of Surgeons National Quality Improvement Program. Presented at: the 77th Annual Meeting of the Southeastern Section, American Urological Association (SESAUA); March 14-17, 2013; Williamsburg, VA. Abstract 53.

				National Comprehensive Cancer Network. NCCN Guidelines and Compendium Update: Bladder Cancer. 

http://www.nccn.org/about/news/ebulletin/2012-11-26/guidelines_compendium.asp

				Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. Neoadjuvant chemotherapy in invasive bladder cancer: a systematic review and meta-analysis of individual patient data Advanced Bladder Cancer Meta-Analysis Collaboration. 

				Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. Neoadjuvant chemotherapy in invasive bladder cancer: update of a systematic review and meta-analysis of individual patient data Advanced Bladder Cancer Meta-Analysis Collaboration. 

. 2005;48(2):202-205. Published online ahead of print, April 21, 2005.

				Winquist E, Kirchner TS, Segal R, Chin J, Lukka H. Neoadjuvant chemotherapy for transitional cell carcinoma of the bladder: a systematic review and meta-analysis. 

				Meeks JJ, Bellmunt J, Bochner BH, et al. A systematic review of neoadjuvant and adjuvant chemotherapy for muscle-invasive bladder cancer. 

 2012;62(3):523-533. Published online ahead of print, June 1, 2012.

				Sternberg CN, Bellmunt J, Sonpavde G, et al. ICUD-EAU International Consultation on Bladder Cancer 2012: chemotherapy for urothelial carcinoma-neoadjuvant and adjuvant settings. Eur Urol. 2013;63(1):58-66. Published online ahead of print, August 14, 2012.

Articles

Preoperative chemotherapy was not a predictor of postoperative complications, nor did it increase the length of hospital stays or surgical complications among patients undergoing radical cystectomy for muscle-invasive bladder cancer.

Data Support Safety and Benefit of Chemotherapy Before Radical Cystectomy

Current T staging for renal cell carcinoma (RCC) is based on maximal tumor diameter. But this assessment does not capture the full picture of tumor volume (TV), which data have shown to be more predictive of survival and recurrence in pT1a clear cell RCC (ccRCC).

Surpassing the standard one-dimensional view in prognostic power, researchers have found, is a calculation for TV that captures height, width, and length of the tumor, taking into account that tumors often develop not in uniform round spheres, but in irregular and varying widths, lengths, and depths.

Jacob Jorns, MD, of the Mayo Clinic in Jacksonville, Florida, presented data from two analyses focused on TV in RCC during the 2013 Annual Conference of the Southeastern Section of the American Urological Association. One analysis substantiated the shortcomings of the T-staging recommendation of largest tumor diameter and introduced a more robust assessment—true tumor volume (TTV). Another assessed the correlation between radiologic and pathologic TV in localized RCC.

, the researchers evaluated records from 2180 patients who underwent radical or partial nephrectomy for pT1a ccRCC between the years of 1985 and 2006, and for whom the three tumor dimensions were available in pathology reports, enabling tumor size and volume to be compared. TV was defined as (π/6 x height x length x width). TTV was calculated by plugging the three tumor dimensions reflected in pathology reports into the TV formula. Alternative tumor volume (ATV), utilizing the onedimensional views of standard T staging, was calculated by using the largest tumor dimension to represent all three values—height, length, and width&mdash;in the TV formula, as a means of comparison.

For 1547, or 71%, of the 2180 patients whose tumor size and volume could be compared, each of the three tumor dimensions differed one from another. The mean difference between ATV and TTV was 194 cm3 (standard deviation 485; median 42; range 0-11,608), and statistically significant (

	The difference between the TTV and ATV calculations increased significantly with increasing stage of a patient’s primary tumor (

	Motivated by this finding that TTV had more prognostic value than size alone, the same group went on to evaluate the correlation between radiographic and pathologic TV in localized RCC.

 The aim, the authors wrote, was to determine if presurgical imaging could be employed that would be as accurate as pathology in determining TV, thus helping to inform treatment decisions. Several investigations have looked at preoperative imaging of tumor size, Jorns noted, but this may be the first study to assess TV in this manner.

	Using the institution’s nephrectomy registry, the researchers identified 144 patients whose records included three TV measurements. They then correlated preoperative TV imaging with TV as determined by pathologic specimens, to identify and measure differences.

	The investigators found a strong correlation between the TV measurements arrived at through imaging and via surgery (r=0.95). The correlation was similar for CT versus MRI (r=0.93, r=0.98), men versus women (r=0.94, r=0.98), clear cell versus other subtype (r=0.94, r=0.97), and obese versus non-obese (r=0.99, r=0.89).

	TV did not differ between CT and MRI, but the correlation between the results of imaging and pathology was weaker among pT1a tumors when compared with T2 and T3 tumors. A stronger correlation was noted among patients with a BMI >30 than with thinner patients, suggesting that obesity may promote better imaging.

	The finding that neither imaging modality proved better than the other is potentially meaningful because, as Jorns noted, with an increased incidence of small localized renal tumors, there is a need for more and better preoperative tools for decision-making.

	Commenting on the data from both studies was corresponding author David Thiel, MD, associate professor of Urology at the Mayo Clinic in Florida. “It turns out that RCC tumors are not round balls but ellipsoids, and utilizing one-dimensional tumor size to indicate true tumor volume is inaccurate,” he said. “Our study shows that tumors very rarely have the same size in any of the three dimensions. And the imaging study demonstrates that our current cross-sectional imaging is very accurate in determining true tumor volume.

	“Given our recent data that RCC tumor volume is more predictive of survival than tumor size alone, and with the recent attention given to watchful waiting for small renal masses as well as alternative therapies such as ablation, we need to start talking in terms of tumor volume rather than tumor size alone to improve prognostic accuracy.”

				Jorns J, Thiel D, Lohse C, et al. Largest diameter is not an accurate determinant of renal cell carcinoma tumor volume. Presented at: the 77th Annual Meeting of the Southeastern Section, American Urological Association (SESAUA); March 14-17, 2013; Williamsburg, VA. Poster 126.

				Jorns J, Thiel D, Arnold M, Cenigliaro J, Parker A. Evaluation of the correlation between radiographic and pathologic tumor volume in localized RCC. Presented at: the 77th Annual Meeting of the Southeastern Section, American Urological Association (SESAUA); March 14-17, 2013; Williamsburg, VA. Abstract 43.

Current T staging for renal cell carcinoma does not capture the full picture of tumor volume, which data have shown to be more predictive of survival and recurrence in certain types of cancer. 

In Some Renal Cell Tumors, Volume More Prognostic Than Size

If the job of oncology nurse comes with satisfactions— the gratitude from patients and family members for compassionate care rendered, shared happiness with patients who experience good outcomes&mdash; it also comes with an abundance of stress, even more than what oncologists and other medical professionals experience, according to research.

The stress can lead to burnout and to “compassion fatigue,” compromising job satisfaction and careers, and damaging personal lives.

Because they are working with patients “at one of the most significant times of their lives,” it is common for oncology nurses to develop an unusual closeness, said Penny Damaskos, PhD, LCSW, OSW-C, program coordinator and clinical supervisor at Memorial Sloan-Kettering Cancer Center (MSKCC), speaking as part of a panel on compassion fatigue at the 38th Annual ONS Congress.

		Lowered frustration tolerance/increased outbursts of anger or rage

		Self-destructive, self-loathing behaviors

		Difficulty separating work from personal life

		Patient’s suffering mirrored in helper (eg, loss of hope, intrusive thoughts, feelings of helplessness)

Physical symptoms as well as psychological ones may appear in nurses as a result, often with impacts both at home and at work—where lowered productivity, increased work absenteeism, or leaving the work setting altogether have been reported under these circumstances (

Damaskos and others on the panel discussed how compassion fatigue arises from the desire to relieve another person’s suffering. Differing from “burnout” which is grounded in nurses’ reaction to the work environment (although there are shared symptoms), compassion fatigue has its source in the clinical work itself, and in the manner by which nurses internalize interactions with patients. For an oncology nurse, interactions with cancer patients, especially those who are hospitalized, often conclude with loss (of patients to death) and to internalized grief. From constant exposure to the suffering of fellow human beings, nurses may develop feelings of helplessness.

The scope and range of recent published research on compassion fatigue and burnout are evidence of the urgency of these issues to the field of oncology nursing. A search using Google Scholar returned 493 results since 2009, according to panelist Katherine Janzen, RN, MN, ONC-C, assistant professor, School of Nursing at Mount Royal University in Calgary, Canada. Proquest and the Allied Health Database contain 284 articles on compassion fatigue in oncology nurses. Among themes that recur is the recognition of compassion fatigue as an imperative nursing agenda item for action and intervention.

Panelist Katrina Fetter, BSN, RN, OCN, staff nurse and assistant manager at Lancaster General Hospital in Pennsylvania, pointed to her institution’s successful strategies to deal with compassion fatigue. Lessons from this experience, she said, include instituting an open dialogue with staff on the subject of stress and its consequences and a process of regular reevaluation. Build a formal program that is supported by the literature, Fetter advised, but “remain flexible,” to better respond to specific problems as they arise.

The end goal for nurses, said Fetter, is to develop healthy, therapeutic relationships with patients, but also to protect themselves by cultivating emotional boundaries.

Memorial Sloan-Kettering Cancer Center has incorporated within its system an “institution-wide” push toward recognition of staff burnout and promotion of wellness, said Damaskos. Institution-wide seminars and respite programs and a partnership between Employee Wellness and the Department of Social Work have been incorporated within the hospital system. At the level of the individual, she said, there are support groups on inpatient units and in outpatient facilities to address job stressors, and these services are available to all staff.

Among several other initiatives at MSKCC, Damaskos described an ambulatory nursing program, which has explored such topics as “Bereavement: Coping for Healthcare Professionals,” “Therapeutic Communication: Discussions about Death and Dying,” and “Compassion Fatigue, Burnout and Resilience.” Also at MSKCC, a peer-to-peer pilot project has been launched for nurses to promote self-awareness of the impact of their work and to serve as an opportunity for discussion of topics central to maximizing their productivity, sensitivity, and resilience— including maintaining positivity, fostering emotional insight, and life balance and spirituality.

: leave work at work, recognizing that compassion fatigue and burnout are part of the job description. Allow for respite times within work days as well as outside of work.

Build supportive professional relationships

 and networks through professional and educational support systems (eg, mentors).

in professional and personal life. Get involved in projects that interest you. Focus on mentoring others.

			Gentry JE, Baranowsky AB, Dunning K. ARP: the accelerated recovery program (ARP) for compassion fatigue. In: Figley CR, editor. Treating Compassion Fatigue. New York: Brunner-Routledge; 2002:123-137.

			Jackson D, Firtko A, Edenborough M. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. 

If the job of oncology nurse comes with satisfactions it also comes with an abundance of stress, even more than what oncologists and other medical professionals experience, according to research.

Compassion Fatigue and the Challenge of Developing Resilience

Complementary and alternative medicine (CAM) has been in the mainstream of healthcare for thousands of years in China, and in India where Ayurveda has long been practiced as a holistic approach to health, based on maintaining balance in body, mind, and consciousness through proper diet and lifestyle, as well as herbal remedies.

Now, in the United States, a growing proportion of cancer patients and cancer survivors are adopting CAM diets and taking herbs, vitamins, and supplements for their healing properties–not in place of standard cancer therapy, but along with it and beyond treatment.

In this setting, research shows, the hope and promise of CAM nutrition comes with varying degrees of supportive evidence. But CAM and the concept of integrative care has joined the elite among medical research areas with a special unit within the National Institutes of Health: the National Center for Complementary and Alternative Medicine (NCCAM [

As much as 44% of all cancer survivors use CAM therapies, according to findings from a study by Judith Fouladbakhsh, PhD, APRN, and colleagues. Fouladbakhsh, associate professor at Wayne State University College of Nursing, and Liana Wheatley, BA, RN, OCN, a medical oncology nurse from Texas Oncology, reviewed the potential benefits and risks of CAM diets and nutritional supplements for cancer and other wellness goals at ONS 2013.

Anticancer diets, although they differ in guiding philosophies, use of specific supplements, food preparation (if any), and other particulars, typically share certain features. Most recommend high levels of antioxidants and phytochemicals, which are biologically active compounds found in plant-based foods such as fruits, vegetables, beans, and grains. Thousands of phytochemicals have been identified, but only a small fraction has received close scientific examination and verification of health benefits. Better known among the scientifically validated compounds are beta carotene and other carotenoids, ascorbic acid (vitamin C), folic acid, and vitamin E.

Also common among anticancer and other CAM diets is a recommendation for plant-based (vs animal-sourced) protein as well as fiber, omega-3 and omega-6 fatty acids and oils, minerals, and polyphenols, which are found in green tea, and curcumin (the major component of turmeric). Among a number of CAM diets discussed by Fouladbakhsh and Wheatley in their ONS overview, certain ones are labeled as “anticancer” diets, including the Dr. Oz Anti-Cancer Diet, Dr. Moerman’s Anti-Cancer Diet, The Maker’s Diet, and the Paleo Diet.

Herbs have been used for thousands of years as a form of healthcare, and evidence is accumulating in support of the potential of some to affect cancer risk and progression at the cellular level. Examples include resveratrol, a phytonutrient found in grapes (and red wine), cranberries, blueberries, and other foods; ginseng, which contains saponins, which possess antitumor effects, such as antiangiogenesis; ginkgo biloba, for its gene-regulatory and anti-angiogenic properties; lycopene (found in tomatoes), which may affect cancer risk; and green tea, which contains polyphenols and catechins that can inhibit cancer cell growth and proliferation.

Integrative medicine and incorporating standard medicine with CAM is “where it’s all going,” according to some nursing professionals. But there are also risks, especially to cancer patients. As NCCAM points out, these include evidence for interference with some standard cancer treatments.

Experts agree that the research basis for CAM diets and supplements is still inconclusive and that more extensive, randomized clinical trials are needed (

. 2010;51(8):1414-1423). Clinical practice guidelines for integrative oncology (

 2009;7(3):85-120) make these cautions specific, saying that, based on a review of the literature, “…specific dietary supplements are not recommended for cancer prevention” and that providers should evaluate a patient’s use of dietary supplements prior to the start of therapy to assess for possible side effects and interactions.

A growing proportion of cancer patients and cancer survivors are adopting CAM diets and taking herbs, vitamins, and supplements for their healing properties-not in place of standard cancer therapy, but along with it and beyond treatment.

Patients and Survivors Harness the Healing Potential of Diets, Herbs, and Supplements

Any woman, upon receiving news of an inherited form of gynecologic cancer, may be justified in feeling that she faces a form of double-jeopardy—not only a cancer diagnosis but one that may place her family at a higher-than-average risk of a potentially deadly disease.

Enter the oncology nurse navigator, a professional designation new enough that its core competencies are still under development, but who can draw on genetic and genomic competencies for which all nurses are responsible. Essential competencies in genetics/genomics were only recently defined for the baccalaureate-level nurse by the American Nurses Association (ANA) in 2005 and for nurses with graduate degrees in 2012.

Still, cancer centers are responding to a need made manifest by advances in the sciences of genetics/ genomics, the availability of precise genetic testing and the ongoing development of new targeted therapies.

Fox Chase Cancer Center (FCCC) in Philadelphia and Northside Hospital Cancer Institute in Atlanta have established model oncology nurse navigator programs with integrated processes for assessment, identification, referral, education, care, and support for patients whose gynecologic cancers may be genetically-based.

The Fox Chase GYN navigation program was piloted at the end of 2010 with one nurse navigator in a part-time role. That role was expanded to a full-time position about 1 year later, and a second navigator was added in 2013 to manage/navigate a volume of 70 to 90 new patients each month, according to Carol Cherry, MSN, RN, AOCNS, APNG, and herself a GYN oncology nurse navigator there.

A map of the interface among healthcare professionals at FCCC reveals the complexity of navigating care for a GYN cancer patient. At FCCC, the GYN oncology nurse navigator functions within a service line model that includes dedicated gynecologic oncology surgeons, medical oncologists, radiation oncologists, nurse practitioners, RNs, nursing aides, surgical, medical, and radiation oncology fellows, social workers, GYN-focused clinical trials staff, an RN administrator from the Women’s Cancer Center, a risk assessment RN, and a GYN pathologist.

The FCCC program has measured its success by recognized metrics, and it has been shown to be worth the investment of time and resources (Box).

Cherry explained the opportunities to incorporate genetics/genomics in the navigator role. These include:

		Recognizing family history red flags and alerting clinical staff.

		Facilitating referral to Clinical Genetics at the hospital prior to or in conjunction with the GYN appointment.

		Tracking results of microsatellite instability analysis and immunohistochemistry (IHC) of endometrial tumors.

		Meeting patients in the clinic as needed following endometrial tumor testing.

New at FCCC, as of 2011, is a universal Lynch Syndrome screening strategy. All new patients with surgically resected or biopsied endometrial and colorectal cancers receive IHC as the primary mismatch repair (MMR) screen. If IHC shows a loss of PMS2, MSH2, and/or MSH6, patients are referred for genetic counseling. The navigator, whose background includes working in Clinical Genetics, helps facilitate referrals.

Penny Daugherty, RN, MS, OCN, oncology nurse navigator at Northside Hospital Cancer Institute, emphasized the role of patient support and partnership. This support begins early. Upon a patient’s first learning of a genetically-based cancer, she said, “what’s important is to quell panic,” and to “partner with the patient in reestablishing a sense of control.”

Another early step in the caregiving provided by the nurse navigator is to assess the readiness of the patient to accept and process information about genetic counseling—all the while maintaining an acute awareness of signs of distress. During a conversation with the patient and perhaps loved ones, Daugherty said (and demonstrated in a sample dialogue), “…maintain an awareness of the patient’s body language, especially indicators of fear, resistance, or avoidance” and provide reassurance.

Before concluding this first meeting, Northside nurse navigator/genetics counselors offer patients a FAQ sheet with a pen and notes page, along with instructions to read and jot down questions or comments, which, as the counselor explains, “…we will explore at the next meeting,” giving the patient the comfort of knowing they have another opportunity to speak, and to form questions, once the edge of panic subsides.

		Success of the Oncology Nurse Navigation at Fox Chase Cancer Center

	↓ fear and anxiety at first appointment

Throughout the care continuum, Daugherty advised her colleagues, “maintain availability”—be reachable for questions such as the meaning and consequences of genetic testing. For BRCA mutation— positive patients, she added, nurses should provide information about poly (ADP-ribose) polymerase (PARP) and the promise of PARP inhibitors, which are undergoing clinical trials in individuals with BRCA1/BRCA2 mutations.

Cancer centers are beginning to establish oncology nurse navigator programs with integrated processes for assessment, identification, referral, education, care, and support for patients whose gynecologic cancers may be genetically-based.

Barbara Jones

Articles

Data Support Safety and Benefit of Chemotherapy Before Radical Cystectomy

In Some Renal Cell Tumors, Volume More Prognostic Than Size

Compassion Fatigue and the Challenge of Developing Resilience

Patients and Survivors Harness the Healing Potential of Diets, Herbs, and Supplements

Integrating Genetics and Genomics in GYN Patient Navigation