	At the 2012 NCCN annual meeting, a panel of oncology nurses discussed the essential components of healthcare for survivors, challenges survivors face, and survivorship program models.

	“An individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life,” said Fran Zandstra, RN, MBA, OCN, director of the Cancer Survivorship Program at the University of Texas MD Anderson Cancer Center in Houston. “Survivorship care…must be tailored to each person’s tumor, treatment, and health history,” Zandstra added.

	According to Zandstra, the four essential components of survivorship care include surveillance for the detection and treatment of late malignancy recurrence; prevention for behavioral lifestyle changes to reduce risk/prevent cancer; intervention for consequences of cancer and its treatment, including medical and psychosocial effects; and coordination between specialists and primary care providers to meet all of a survivor’s healthcare needs.

		Joanne Lester, PhD, CRNP, ANPBC, AOCN®

	Survivorship presents a multitude of challenges, according to Joanne Lester, PhD, CRNP, ANPBC, AOCN®, a research scientist and oncology nurse practitioner at the The Ohio State University Comprehensive Cancer Center in Columbus. Physical challenges include pain, discomfort, cognitive changes, skin and mucosal changes, bone health, neuropathies, cardiopulmonary challenges, fatigue, sleep-wake disturbances, gastrointestinal and genitourinary symptoms, sexuality and reproductive issues, and lymphedema.

	Psychological challenges include anxiety, posttraumatic stress, substance abuse, depression, suicide, spirituality questions, and end-of-life transition.

	Practical challenges include personalization of information and care, economic burden, employment, and family-related issues.

	Mary S. McCabe, RN, MA, director of the Cancer Survivorship Initiative at Memorial Sloan-Kettering Cancer Center in New York City, finished the discussion by describing survivorship program models.

	A multidisciplinary clinic allows patients to be seen by different providers during one clinic visit and provides a comprehensive approach to survivorship, but the program may be difficult to coordinate and reimbursement for all providers is a challenge.

	On the other hand, a disease- or treatmentspecific clinic, one that focuses on one specific disease category or intervention, allows for a focused scope of practice. However, this approach may exclude survivors with the greatest needs.

	Other cancer survivorship program models include a consultative service that covers general survivorship care and an integrated care model that involves embedding survivorship into the oncology clinic as part of the function of the treatment team.

	In establishing a survivorship program, nurses should determine what type of model might work within their institution, establish simple metrics, get support from leadership and peers, understand what needs to be implemented, and be willing to revise.

Articles

At the 2012 NCCN annual meeting, a panel of oncology nurses discussed the essential components of healthcare for survivors, challenges survivors face, and survivorship program models.

Essential Components of Survivorship Care

	Although oral treatments have revolutionized cancer care, their use presents challenges to both patients and providers. Peg Esper, MSN, RN, AOCN®, ANPBC, an adjunct clinical instructor at the University of Michigan Comprehensive Cancer Center in Ann Arbor, discussed the management of oral oncolytic treatment at the 2012 NCCN Annual Meeting.

	Oral agents provide a variety of benefits versus standard infusion chemotherapy. For patients, self-administering treatment is empowering and the reduction in clinic visits is less disruptive on their career and personal life. For providers, oral treatments offer greater flexibility to modify or stop treatment during a cycle in order to control side effects. These benefits are mitigated by several challenges, including financial strain, patient education challenges, patient compliance issues, and toxicity management.

	According to Esper, the high cost of oral oncology agents is a problem for many patients who either have issues with coverage or steep copays. Additionally, many patients have to deal with the Medicare Part D coverage gap or “donut hole.” While some states have laws requiring equal coverage for intravenous and oral agents, most states lack such policies. To address these financial issues, most oral drug manufacturers offer patient-assistance programs.

	Oral oncology agents also create educational challenges, as patients must fully comprehend how to administer and manage their own treatment. Each agent has unique side effects that need to be monitored, and patients need to know when it is necessary to call their healthcare provider or seek emergency care.

	Even with comprehensive patient education, other issues interfere with successful management of oral agent toxicities. The reduction in clinical visits affords less time to monitor patients. This means an enhanced reliance on patient reporting, which is often incomplete regarding toxicities experienced between cycles of therapy. According to Esper, there are also logistical issues in the clinical setting. Some of the nursing staff may not see patients given prescriptions for oral agents during a clinic visit. Additionally, patient education visits may not be scheduled before treatment begins.

	Relying on patients to self-deliver care also creates adherence issues with oral oncolytics. Some of the factors that impact adherence include cognitive issues, depression, lack of support, a lack of belief in treatment value, and financial concerns. According to Esper, “over-adherence” is just as problematic as “under-adherence,” as some patients think higher doses will enhance and quicken the treatment.

	Esper recommended several strategies for improving treatment with oral agents, including increasing clinical visits at the start of treatment, offering phone support, prescribing no more than one cycle of therapy, advising patients to keep diaries or logs, and providing educational materials for symptom management strategies.

Although oral treatments have revolutionized cancer care, their use presents challenges to both patients and providers.

Challenges With Managing Oral Cancer Treatments

	Cancer pain management has greatly improved with advances in oral and intravenous medication. However, several challenges still exist in administration. Judith A. Paice, PhD, RN, FAAN, a research professor in medicine-hematology/oncology at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago, Illinois, discussed the management of cancer pain at the 2012 NCCN Annual Meeting.

	According to NCCN guidelines, pain should be assessed for location, duration, intensity, quality (nociceptive, neuropathic, or visceral), timing, and aggravating or alleviating factors. Cancer patients with pain should also be assessed for other symptoms, current therapies, prior treatment response, function changes, family history of substance abuse, and risk factors for aberrant use or diversion.

	“The goals of treatment include prevention, relief of pain, improved function, [and] safety,” Paice said.

	Specifically, she said analgesia versus safety is a major challenge with pain management. For example, while acetaminophen is commonly used for cancer pain, many patients are unaware of how many treatments they are taking that include the drug, increasing their risk of an overdose.

	Currently available treatment options for pain management include non-opioids (acetaminophen or NSAIDs), opioids, adjuvants, and anticancer therapies.

	Opioids are fundamental to good cancer pain management and are available in several forms, including tablets, sublingual tablets, buccal soluable film, and nasal spray. Typically, these agents require prior authorization or partial fills and are associated with a variety of side effects ranging from respiratory depression and sedation to nausea and vomiting.

	Adjuvant options include corticosteroids, antiepilepsy drugs, antidepressants, local anesthetics, NMDA receptor antagonists, and cannabinoids. Corticosteroids can be administered orally, intravenously, or epidurally, and have been shown to be effective in reducing pain. However, corticosteroids may produce psychosis and longterm use may lead to proximal muscle wasting.

	Of the anti-epilepsy drugs, gabapentin is generally the most well-tolerated and is often used for breakthrough pain or neuropathic pain. However, the drug is administered three times per day and may be associated with dizziness and sedation. Pregabalin is another anti-epilepsy drug that has been associated with improved bioavailablity at high doses.

	Antidepressants, including tricyclics (nortriptyline and desipramine) and serotonin—norepinephrine reuptake inhibitors (venlafaxine and duloxetine), have been effective in providing good pain control with limited adverse events. Local anesthetics, such as lidocaine patches or creams, have been effective in treating localized pain.

	Due to the challenges associated with medical marijuana, manufacturers are testing synthetic compounds that target CB1 and CB2 receptors, as these agents provide pain control without the euphoric feeling associated with medical marijuana.

	Overall, Paice said that there are several effective agents available for cancer pain, but practitioners need to be aware of the risk of adverse events and drug-drug interactions associated with these treatments.

Cancer pain management has greatly improved with advances in oral and intravenous medication. However, several challenges still exist in administration.

Challenges and Breakthroughs in Cancer Pain Management

Many targeted therapies are associated with dermatologic side effects, according to Peg Esper, MSN, RN, AOCN®, ANP-BC, an adjunct clinical instructor at the University of Michigan Comprehensive Cancer Center in Ann Arbor. Esper discussed these adverse events at the 2012 NCCN Annual Meeting.

	The most common dermatologic side effects associated with EGFR inhibitors, such as cetuximab (Erbitux) and erlotinib (Tarceva), include papulopustular, xerosis, hypertrichosis, and trichomegaly. Papulopustular most frequently occurs on the face and chest. While the development of rash appears to be correlated with the effectiveness of EGFR inhibitors, the absence of rash does not indicate poor treatment response.

	Prophylactic treatment of EGFR-associated rash involves the use of skin moisturizer creams and ointments, avoidance of excessive sun exposure, avoidance of hot showers or hot water on hands, and avoidance of any alcohol-based products. If a grade 3 rash develops with an EGFR inhibitor, the dose of the agent should be modified and/or an oral steroid added to treatment. However, if a grade 4 rash develops, treatment should be discontinued.

	The dermatologic toxicities most frequently associated with VEGF inhibitors, such as bevacizumab (Avastin) and axitinib (Inlyta), include hand-foot skin reaction, rash or desquamation, hair depigmentation, trichomegaly, paronychia or subungual hemorrhages, xerosis, mucositis, pruritis, bullae, yellowing of the skin and impaired wound healing.

	mTOR inhibitors including temsirolimus (Torisel) and everolimus (Afinitor) are commonly associated with rash. Grade 4 rashes are not common, but if they do occur, treatment should be stopped immediately. Other common symptoms associated with mTOR inhibitors include mucositis and stomatitis.

	BRAF inibitors are associated with rash, photosensitivity, fatigue, pruritus, palmar-plantar dysesthesia, squamous cell carcinomas, and keratoacanthomas. According to Esper, when BRAF inhibitors are used to treat melanoma, it is difficult to tell patients that their treatment is associated with another type of skin cancer.

	Immunotherapy with interleukin-2 may be associated with rash, xerosis, desquamation, pruritis, vitiligo, facial flushing, and stomatitis, while immunotherapy with ipilimumab (Yervoy) may be associated with rash, vitiligo, pruritis, xerosis, and stomatitis.

	Treatment of rash associated with VEGF inhibitors, mTOR inhibitors, BRAF inhibitors, and/or immunotherapies is very similar to that of EGFR inhibitors utilizing creams and ointments and avoidance measures. However, rashes associated with VEGF inhibitors are typically not as severe as with EGFR inhibitors and do not commonly require steroid use.

	Treatment challenges with dermatologic toxicities include patients forgetting details surrounding the start of rash, individual responses to interventions varying greatly, slow improvement with medical treatment, minimal data in the literature for topical applications, late presentation for medical attention leading to complications, and patients avoiding reporting symptoms, Esper said. Overall, monitoring and treating these side effects should be done on an individual patient basis, she added.

Many targeted therapies are associated with dermatologic side effects; the monitoring and treating of these side effects should be done on an individual patient basis.

Managing Dermatologic Toxicities Associated With Targeted Therapies

	With the advent of more targeted approaches to cancer treatment, understanding the genetic basis of breast and ovarian cancers is essential to providing patients with effective preventive and/or management strategies that can improve outcomes. Heather Hampel, MS, CGC, a professor and certified genetic counselor at The Ohio State University Comprehensive Cancer Center in Columbus, discussed the genetic basis for breast and ovarian cancer at the NCCN annual meeting.

	The causes of hereditary susceptibility to gynecologic cancers include hereditary breast-ovarian cancer syndrome, Lynch syndrome (endometrial and ovarian cancer), Cowden syndrome (endometrial and breast cancer), and Li-Fraumeni syndrome (breast cancer).

	Approximately 5% of breast cancers are hereditary and 15% to 20% occur in family clusters, while 10% to 15% of ovarian cancers are hereditary. Heredity breast or ovarian cancer tends to occur at an earlier age and involves multiple generations with cancer or clustering of certain cancers, while sporadic cancer is likely to occur at a later age and occurs as a single or unilateral tumor and is associated with limited family history of cancer.

 account for the vast majority of hereditary breast-ovarian cancer syndrome. 

 mutations increase the risk of primary breast cancer, second primary breast cancer, ovarian cancer, and prostate cancer in men. 

 mutations also increase the risk of breast and ovarian cancer in women, and increase the risk of male breast cancer, as well. In addition, 

 mutations may be associated with an elevated risk of prostate, laryngeal, and pancreatic cancers. Triple-negative breast cancers are more likely due to

 mutations and women aged <60 years with triple-negative breast cancer should be tested, regardless of family history.

-positive cancers are not well understood, individuals of Ashkenazi Jewish descent are ten times more likely to have these mutations than the general public. One in 40 Ashkenazi Jews, both male and female, carries a 

 mutation, while one in 400 carries the mutation in non-Jewish populations.

	The cost of genetic testing for breast and ovarian cancer risk depends on the extensiveness of testing. For comprehensive testing involving both 

 analysis, the cost is approximately $3340; however, most insurance companies will provide coverage if the patient’s need for testing is demonstrated. Follow-up large rearrangement testing is approximately $700 and is not always covered by insurance because the risk of a major rearrangement is rare. Other types of genetic testing include singlesite analysis that costs approximately $475 and evaluates a specific gene that may be found within a family, and Multisite 3 that costs about $575 and looks at three specific mutations commonly found in Ashkenazi Jews.

	According to Hampel, the clinical management of BRCA-positive cancer patients includes increased surveillance, lifestyle changes, chemoprevention, and prophylactic surgery. Surveillance for 

 mutation carriers includes monthly breast self-exams starting at age 18, clinical breast examinations every 6 months starting at age 25, and annual mammography and breast magnetic resonance imaging starting at age 25. Surveillance will also involve ultrasound with color Doppler imaging every 6 to 12 months, starting at 30 to 35 years of age.

	In some BRCA-positive patients, especially in patients with 

 mutations, chemoprevention with tamoxifen may be prescribed. Oral contraceptives may also be used to prevent the risk of ovarian cancer. In the general population, oral contraceptives reduced the risk of ovarian cancer by 40% to 50% after 3 years of cumulative use. However, the benefits and risks of oral contraceptives for chemoprevention and contraception need to be weighed.

	One popular option for the prevention of breast cancer is prophylactic mastectomy, which removes most, but not all, breast tissue. The approach has been shown to reduce the risk of breast cancer by 90% to 95%. Another approach is prophylactic oophorectomy, which decreases the risk of ovarian cancer by 85% to 90%. It is crucial that patients are fully informed of the latest clinical information before selecting either of these options.

 testing might also help guide treatment. Currently, Poly-ADP ribose polymerase (PARP) inhibitors are being studied for the treatment of BRCA-positive breast and ovarian cancers. “PARP inhibitors have the potential to enhance cytotoxicity of cancer treatment and reverse tumor cell resistance,” Hampel said.

Understanding the genetic basis of breast and ovarian cancers is essential to providing patients with effective preventive and/or management strategies that can improve outcomes.

Beth Gilbert

Articles

Essential Components of Survivorship Care

Challenges With Managing Oral Cancer Treatments

Challenges and Breakthroughs in Cancer Pain Management

Managing Dermatologic Toxicities Associated With Targeted Therapies

Genetic Assessment of Breast and Ovarian Cancer Risk