The use of oral agents in treating cancer is not new, but the development of so many agents that require administration over long periods of time has resulted in new challenges. Nurses in healthcare settings that do not routinely provide oncology medications often encounter patients who are undergoing treatment for cancer, and guidelines are sparse for how to prepare nurses for this situation. The following is offered merely as a starting point from which to build educational programs in preparing nurses in other specialties in the administration of oral oncology agents.

What follows is intentionally simplistic as the goal is increased understanding for the novice. So, for the purists: Yes, I am aware that mucositis involves much more, and I would be happy to direct you to more extensive articles if desired. Disclaimers aside, let’s get started.

Chemotherapy agents: What do they do?

Quite simply, cytotoxic chemotherapy works to kill cancer cells by interfering with the cell division process. After exposure to the drug (or drugs), cancer cells ideally die as they try to divide. In this way, chemotherapy is considered specific to rapidly dividing cells. Unfortunately, side effects often occur as the result of the therapy affecting other rapidly dividing healthy cells. Alopecia (hair loss) occurs because hair follicles are rapidly dividing. Mucositis, a breakdown of the mucosa along the gastrointestinal tract, occurs for the same reason. Mucositis in the oral cavity, stomatitis, often is painful and a source of distress for patients when it interferes with the ability to eat or speak. More ominously for the patient being treated with chemotherapy is the impact of depleting blood cell reserves. Severe neutropenia, a drop in neutrophil counts, places the patient at high risk for infection without the reserve to fight it. Anemia, although easily corrected with transfusions and appropriate growth factor use, may affect quality of life because fatigue, shortness of breath, dizziness, and even short term memory loss often result. Thrombocytopenia (a drop in platelets) places the patient at risk for bleeding. However, platelet transfusions are usually reserved for patients with platelet counts of less than 10,000, unless active signs of bleeding are present.

Current Oral Chemotherapy Drugs:

• Altretamine, Hexamethylmelamine, HMM (Hexalen^®, MGI Pharmaceuticals)
• Bexarotene (Targretin^®, Ligand Pharamceuticals)
• Busulfan (Myleran^®, GlaxoSmithKline)
• Capecitabine, Oral 5-Fluorouracil, Oral 5-FU (Xeloda^®, Hoffman-LaRoche Inc.)
• Chlorambucil (Leukeran^®, GlaxoSmithKline)
• Cyclophosphamide (Cytoxan^®, Bristol-Myers Squibb)
• Estramustine (Emcyt^®, Pfizer Inc.)
• Etoposide (VePesid^®, Bristol-Myers Squibb)
• Hydroxyurea (Hydrea^®, Bristol-Myers Squibb)
• Lenalidomide (Revlimid^®, Celgene Corp.)
• Lomustine (CCNU, CeeNu^®, Bristol-Myers Squibb)
• Melphalan (Alkeran^®, GlaxoSmithKline)
• Mercaptopurine (6-MP, Purinethol^®, Teva Pharmaceuticals)
• Methotrexate (Trexall™, Duramed Pharmaceuticals)
• Mitotane (Lysodren^®, Bristol-Myers Squibb)
• Procarbazine (Matulane^®, Sigma-Tau Pharmaceuticals)
• Temozolomide (Temodar^®, Schering Corp.)
• Thalidomide (Thalomid^®, Celgene Corp.)
• Thioguanine (Tabloid^®, GlaxoSmithKline)
• Tretinoin (Vesanoid^®, Roche Laboratories)
• Vorinostat (Zolinza^®, Merck & Co., Inc.)

Molecularly Targeted Therapy for Cancer Treatment (The Small Molecule Drugs)

Currently, the only oral medications in this class of drugs are classified as tyrosine kinase inhibitors (TKIs). Although patients might talk about these medications as their oral chemotherapy, they are not technically chemotherapy in the usual sense of the word.

The simple way to think of how these drugs work is to think of them as blocking a message to the cancer cell's nucleus. Normally, molecules such as growth factors attach to different receptors that exist in cell membranes. These molecules initiate a complex cascade of reactions that basically “send a message” to the nucleus of the cell, telling it what to do.

In cancer, certain receptors are expressed abnormally and numerously. Whenactivated, the message they “send” is essentially, “Let’s Divide. Let’s grow a blood supply. Let’s never die.” The small molecule drugs are able to slip into the receptors and work to slow tumor growth by stopping this message cascade.

Current Small Molecule Drugs:

• Dasatinib (Sprycell^®, Bristol-Myers Squibb)
• Erlotinib (Tarceva™, Genentech, Inc.)
• Gefitinib (Iressa^®, AstraZeneca)
• Imatinib (Gleevec^®, Novartis Pharmaceuticals Corp.)
• Lapatinib (Tykerb^®, GlaxoSmithKline)
• Nilotinib (Tasigna^®, Novartis Pharmaceuticals Corp.)
• Sorafenib (Nexavar^®, Bayer)
• Sunitinib (Sutent^®, Pfizer Pharmaceuticals Inc.)

Notice the similarity of generic names – All of the TKIs end in “-nib,” and they all work similarly. Some work on one type of cell receptor, and newer ones work on multiple types of receptors. They all work to block the messages that stimulate tumor growth.

The most common side effects of these drugs are diarrhea and rashes. Uncomplicated rashes are not a reason to stop the medication, and they often are frequently correlated with a positive effect of the drug on the tumor. Sometimes the rashes are acne-like in appearance, but they will not respond to acne treatments. A key teaching point is for patients to avoid sun exposure because this may exacerbate the rash.

Diarrhea is usually easily managed with loperamide (Imodium^®, McNeil-PPC, Inc.). However, as with all assessments, documenting occurrences and severity, as well as notifying the physician if currently ordered measures are ineffective or inadequate in managing the problem is important.

Biologic Therapy (Hormonal Medications):

Breast Cancer
Several oral hormonal agents have been developed for the treatment of breast cancer. These include tamoxifen (Nolvadex^®, AstraZeneca Pharmaceuticals) and a newer class of drugs, the aromatase inhibitors. The three oral aromatase inhibitors include anastrazole (Arimidex^®, AstraZeneca Pharmaceuticals), exemestane (Aromasin^®, Pfizer, Inc.) and letrazole (Femara^®, Novartis Pharmaceuticals). Tamoxifen is considered to be a hazardous drug and is a known human carcinogen. Gloves should be worn during administration, and the tablets should not be crushed. Also, megestrol (Megace^®), often used for appetite stimulation in the non-oncology setting, is another example of a hormonal agent sometimes used in the treatment of breast cancer.

Prostate Cancer
Oral anti-androgenicagents used in the treatment of prostate cancer include flutamide (Eulexin^®, Schering Corp) and bicalutamide (Casodex^®, AstraZeneca Pharmaceuticals). These are usually given in conjunction with monthly injections of a LH-RH (luteinizing hormone-releasing hormone) such as leuprolide (Lupron^®, TAP Pharmaceuticals, Inc.) or goserelin (Zoladex^®, AstraZeneca Pharmaceuticals).

Administering Oral Chemotherapy and Oral Targeted Biologic Agents (Small Molecule Drugs)

• Prior to giving any of these agents, the nurse should research the medications involved and become familiar with the purpose, usual dosing, drug-specific nursing issues (e.g., with food, without food), anticipated side effects, and symptom management strategies.
• Prior to initiating a first dose of any newly ordered chemotherapy or molecularly targeted agent for the treatment of cancer, the orders should be verified and signed off by two chemotherapy competent care providers (e.g., nurse, pharmacist). The order must also be signed by the physician prior to initiating the first dose.
• For agents that are simply a continuation of a regimen started prior to hospitalization, every effort must be made to ensure that dosing continued in the hospital is the same as at home and as intended by the physician as with other home medications. If the patient is admitted in the evening and is due to receive pills that night, every effort must be made to ensure medication continuation or discontinuation is addressed and documented. Phone orders may be accepted to continue home medications, but a signature from the physician should be obtained within 24 hours.
• When administering these agents, two nurses should verify the dosage and medication given exactly matches what is ordered. The correct patient should be identified by bringing the chart to the room and comparing name and medical record number on the patient's arm band to that on the order sheet in which the chemotherapy or molecular targeted therapy order is written.
• Gloves should be worn during administration. Cyclophophamide, for example, is known to absorb through the skin.
• Chemotherapy drugs, even oral agents, are potentially carcinogenic and teratogenic (may cause fetal abnormalities). Some chemotherapy agents may also be genotoxic (causing alterations in DNA) with exposure. Great care should be taken to avoid exposure. Less information is known regarding the risk from exposure to the biologic agents, but in the absence of data, nurses should err on the side of caution by wearing gloves during administration. No gowns are necessary for administering nonliquid oral agents.
  
  

  Known human carcinogens: busulfan, chlorambucil, cyclophosphamide, melphalan, and tamoxifen.
  Anticipated to be carcinogens: lomustine, procarbazine
  Possibly carcinogenic: etoposide

• DO NOT CRUSH, CUT, BREAK, OR OPEN these tablets or capsules. This would place the nurse at risk for exposure to the drug. If a medication must be crushed, cut or opened, it must be done in a vented biologic safety cabinet for preparation.
• ALL spoons, oral syringes, disposable medicine cups, medications that are to be wasted or other equipment used to administer these agents must be discarded in a biohazardous waste bin.

Patient Education

In teaching the patient, the nurse must be familiar with specific agents being used. Side effects vary among the different drugs in severity and frequency. The nurse should research unfamiliar agents in a drug manual.

A web based source for chemotherapy drug information can be found here.

Educating newly diagnosed patients with cancer regarding potential adverse effects of prescribed medications is important. Verbal teaching and written information should be given. Providing reassurance regarding the extensive supportive care available to help prevent some and manage the unavoidable side effects is equally important.

Patients may find the ChemoCare Web site beneficial, which is exceptional in keeping information at an understandable level. Education sheets can also be printed from this site regarding specific drugs and other cancer related questions.

Nurses should be aware of the following common side effects:

Neutropenia—As white counts drop to critically low levels, the patient becomes at high risk for contracting infections. Teaching the patient regarding the need for good hygiene, including frequent hand washing, may help prevent sepsis.
Nurses should also be aware of the severe immune compromise these patients may have and approach the patient appropriately. Nurses with colds should reconsider caring for the patient.

Precautions that may help prevent infection when neutropenic: Avoid gardening. Avoid large crowds. Wear a surgical mask in public. Ensure food is fully cooked. If eating fresh fruits and vegetables, ensure they are cleansed adequately prior to peeling. Ideally, some say, fresh fruits and vegetables should not be eaten because of the risk of microbial exposure. For the same reason, it may be helpful to have no flowers or plants in the neutropenic patient’s room because of risk of fungal exposure and microbial growth in the stagnant water.

Another important teaching point is what to do when fevers occur at home. Instruct the patient to call the doctor no matter when the fever occurs. If the patient is sent to the emergency room, be sure that the patient knows to tell the staff on duty that he or she has both a fever and has received chemotherapy. Hours make a difference in the patient's chance for fighting a neutropenia-associated infection. Antibiotics must be started quickly. The patient should never feel like it is okay to “wait until morning.” Also, make sure they have a thermometer and know how to use it at home.

Growth factor support (G-CSF and GM-CSF) has helped change the face of oncology by achieving shorter and less severe periods of neutropenia. However, growth factors may not always be clinically necessary.

NeutroPhil is an ONS patient education booklet developed to help the patient understand neutropenia and what they can do to prevent infection, It can be found online here.

Thrombocytopenia—As platelet counts drop, the patient becomes at high risk for bleeding. Recommend soft toothbrushes, and if the patient does not floss, this is not the time to start. If the patient does floss, teach them to be very gentle and stop at the first sign of gum bleeding.

The patient needs to avoid activities that put them at risk for injury. If they use razors, they need to switch to an electric razor. The patient needs to understand the seriousness of their bleeding risk. Keep it simple by telling the patient, “If you cut yourself, you are going to bleed, and you’ll have a hard time getting the bleeding to stop” when platelet levels are low.
Also, the patient should be taught signs and symptoms of bleeding in order that they may know when to notify the physician.

Some of those signs: Nausea and vomiting with coffee ground emesis, unexplained or spontaneous bruising or petechiae, gum bleeding, epistaxis (nosebleed), tarry stools, frank blood in stools, dropping blood pressure, tachycardia.

Anemia—Anemia is managed through the use of transfusions and growth factor support (Epogen^®, Amgen, Procrit^®, OrthoBiotech Inc., Aranesp^®, Amgen). Sometimes, rather than use a set of rigid guidelines, support of anemia may be dictated by whether the patient is symptomatic. The nurse must assess for symptoms of anemia as well as to teach the patient to watch for symptoms to ensure appropriate treatment. Symptoms include: Shortness of breath with exertion, dizziness on standing, fatigue, weakness, decreased short-term memory, and sometimes chest pain.

Fatigue—Often correlated with anemia, fatigue can also be a direct effect of the chemotherapy and other treatment modalities, as well as an effect of the tumor activities. Besides managing anemia, teaching patients the benefits of moderate exercise as tolerated is important. Exercise is something patients can do for themselves to help reduce fatigue that has the support of clinical data.

Chemotherapy Induced Nausea and Vomiting—Many supportive medications are available for managing nausea. Most of the oral cancer agents are not highly emetogenic (likely to cause nausea and vomiting).

The two highly emetogenic oral agents (likely to cause emesis in > 90% of people without preventive agents) include hexamethylmelamine and procarbazine. Moderately emetogenic agents include: cyclophosphamide, etoposide, temozolomide, vinorelbine, and imatinib.

If no antiemetics are ordered for the above medications to support the patient, the nurse should confirm with the physician that the omission is intentional. The goal is to prevent initial episodes of nausea and vomiting because adequately controlling nausea and vomiting once it occurs is more difficult.

ASCO (American Society of Clinical Oncologists), NCCN (National Cancer Center Network), MASCC (Multinational Association of Supportive Cancer Care), and ONS (Oncology Nursing Society) have all issued similar guidelines for the prevention of CINV. The nurse should be familiar with CINV prevention prior to administering chemotherapy.

For highly emetogenic chemotherapy, these national guidelines recommend utilization of

• An NK1 receptor antagonist (aprepitant given at 125 mg on day 1, and 80 mg on days 2 and 3).
• A serotonin-receptor antagonist (ondasetron, granisetron, or palonosetron).
• A corticosteroid (typically dexamethasone).

Use of aprepitant may also be considered with moderately emetogenic chemotherapy.

Bibliography

Polovich, M. (Ed.). (2003). Safe Handling of Hazardous Drugs. Pittsburgh, PA: Oncology Nursing Society.

Polovich, M., White, J.M., & Kelleher, L. (Eds.). (2005). Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Pittsburgh, PA: Oncology Nursing Society.

What Inspired Me to Become an Oncology Nurse?

Patricia Albanese, RN, OCN^®
albanesp@mskcc.org

My introduction into the nursing world began when I was 18 years old. I became a volunteer at a local hospital to see if nursing might be a career goal for me. The first day on the job I knew that I had found my profession. My first job after nursing school was at St. Michael’s Medical Center in Newark, NJ on a renal unit. Most of the patients were either chronically or terminally ill.  One exception was the patient in room 302B.  His name was Vinny, a 29 year-old who was admitted with a diagnosis of fever with unknown origin. After an extensive work-up, a diagnosis of bacterial endocarditis was confirmed. Five weeks of IV Vancomycin and a lot of TLC from me placed him back to his usual state of health. Two years later we walked down the aisle and began to build a lifetime of dreams and a family filled with happiness. Five years after we were married we were challenged with cancer. At the age of 37, Vinny was diagnosed with squamous cell carcinoma of the ethmoid sinus, a rare but deadly cancer. Surgery, chemotherapy, and radiation became part of our daily lives for the next three years. In 1989, Vinny lost his fight with cancer. I was left alone as a young widow with two small children, and I had to figure out how to continue with life without my soul mate. I went back to work at St. Michael’s Medical Center and was asked to take a position in the outpatient hematology/oncology unit. How could a grieving single mother ever help these patients with cancer with their own issues of mortality?

After working with these patients for about six months, I realized that God actually chose me to do this work by giving me the experience I lived through with my husband. I knew first hand what mucositis, diarrhea, vomiting, and fatigue meant to a patient five to seven days after chemotherapy. I knew the difficulty of scheduling childcare arrangements for frequent doctor appointments. I knew what it meant to fear not being able to provide financial stability for your family. I knew that the physical debilitation of his illness was not a passage in life at the age of 37. Vinny is and always will be my inspiration to care for others diagnosed with cancer.

PEPID™ Gets PEP^®

Michael Smart, RN, BSN, OCN^®
nursemrsmart@aol.com

Pepid™ RN ONS Suite^® has undergone many important revisions since first being reviewed in this newsletter (Chemo SIG August 2006). Although perhaps still not living up to the claim of being a one-stop for all your information needs, PEPID RN ONS Suite is impressive in its comprehensive coverage of information oncology nurses might need. The most significant recent additions include the ONS Putting Evidence into Practice (PEP^®) cards and long overdue chapters on leukemia and Hodgkin lymphoma. In daily practice, the nursing drug reference of the program will likely be most utilized, but many other tools and resources remain important components. A medical dictionary, medical calculators, a nursing procedures manual, a laboratory reference manual, and drug interaction and IV compatability tools make PEPID a great resource for oncology nurses. The program is available by subscription either online or in PDA format. For more information, click here: www.pepid.com.

What's New in Oncology?

Compiled by Michael Smart, RN, BSN, OCN^®
nursemrsmart@aol.com

Many developments in oncology have occurred since our last issue, and the intent of this column is merely to provide brief summaries with links provided for those desiring the more extensive information to be found in the original articles.

Medications:

• Deferesirox (Exjade^®, Novartis Oncology) is used for iron chelation therapy in patients receiving large numbers of red blood cell transfusions. Patients should have liver function monitored at least monthly while on defersirox therapy as cases of fatal liver failure have been noted while on therapy. Risk factors include age over 55 and pre-existing organ failure. For more information, click here: Exjade Liver Failure
• Cituximab (Erbitux^®, Bristol-Myers Squibb & Imclone), used in the treatment of colorectal and head and neck cancers, is known to carry the risk of hypersensitivity reactions related to the drug being a chimeric monoclonal antibody. A regional phenomenon of higher prevalence of reactions was described in the New England Journal of Medicine (NEJM). Researchers noted that IgE antibodies to cituximab were present prior to treatment in the majority of patients who had reactions. Of 76 patient cases examined in Tennessee, Arkansas, and North Carolina, 25 patients (32.9%) had pretreatment antibodies. 17 patients of these had hypersensitivity reactions. Looking at the prevalence of the antibody control, 20.8% of subjects in Tennessee, 6.1% in California, and 0.6% in Boston exhibited the antibody. Knowing about the presence of the antibodies in an individual may be helpful in predicting hypersensitivity reactions. For more information, click here: Cituximab Anaphylaxis NEJM 3/13/08
• Erythropoietin stimulating agents: Box warnings for Epogen^® (Amgen), Procrit^® (Ortho Biotech), and Aranesp^® (Amgen) have been updated as additional studies have noted increased risk when utilized to obtain hemoglobin levels greater than 12g/dL. The new warning reads: “ESAs shortened overall survival and/or time to tumor progression in clinical studies in patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers when dosed to target a hemoglobin of ≥ 12 g/dL.” For more information, click here: AMGEN Letter
• Methynaltrexone bromide (Relistor™, Wyeth & Progenics) — The FDA has granted approval for Relistor™ in the treatment of opioid-induced constipation in the terminally ill. Opioids cause constipation by causing the smooth muscles of the intestinal tract to relax. Relistor, an injectable medication, works as an inhibitor that prevents opioids from acting on the smooth muscles. The medicine should not be used if bowel obstruction is suspected. For more information, click here: New Option for Constipation

Brain Tumors:

• Frankincense—As reported by NCI, a phase II clinical trial is seeking to determine if the addition of an herbal remedy to standard treatments may benefit glioma patients in terms of reduction in brain edema. The remedy in question, resin from the Boswellia serrata tree (frankincense), is hoped to benefit patients through its anti-inflammatory properties. For more information, click here: So, That's What Frankincense Is For!

Breast Cancer:

• Bevacizumab (Avastin^®, Genentech, Inc.) has received FDA approval for treatment of metastatic HER2-negative breast cancer in combination with paclitaxel for chemotherapy-naive patients. The addition of bevacizumab has demonstrated an increase in progression-free survival (11.3 months versus 5.8 months), but not overall survival. Patients received paclitaxel 90mg/m2 weekly x3 followed by one week off therapy and bevacizumab 10mg/kg every 14 days. Bevacizumab therapy costs approximately $8,000/month, and the FDA approval in this setting may alleviate difficulties obtaining insurance coverage. For more information, click here:Breast Cancer and Bevacizumab
• Mammography after 80—A study reported in the Journal of Clinical Oncology noted that although routine mammography in women older than the age of 80 is able to detect breast cancers at an earlier stage, clear benefits in survival outcomes were not demonstrated. For the complete article, click here: JCO Mammography
• Paclitaxel Dosing Schedule—As reported in the NEJM, patients with breast cancer who receive weekly paclitaxel may benefit in terms of disease-free survival compared to those receiving standard treatment with paclitaxel every three weeks. However, patients who receive weekly paclitaxel were noted to have a higher incidence of neuropathy. For more information, click here: NEJM Weekly Paclitaxel
• After Tamoxifen: As reported in the Clinical Journal of Oncology, post-menopausal women who have completed 5 years of tamoxifen therapy may benefit from the use of an aromatase inhibitor such as letrozole or exemestane. For more information, click on links to the articles below:

• JCO Exemestane
• JCO Letrozole
• JCO Letrozole & Quality of Life

Colorectal Cancer:

• As reported in CA: A Cancer Journal for Clinicians, the American Cancer Society (ACS) guidelines for colorectal cancer screening in asymptomatic adults starting at the age of 50 have been updated and include a preference for tests that screen for both adenomatous polyps and cancer. To see the guidelines, click here: Colorectal Screening Guidelines Updated
• Anal Carcinoma: Replacment of mitomycin with cisplatin did not show an improvement in disease free survival and resulted in much higher rates of colostomy requirement according to a study in the Journal of the American Medical Association. For more information, click here: Mytomycin versus Cisplatin

Leukemia:

• Chronic Lymphocytic Leukemia(CLL): The FDA has approved bendamustine (Treanda^®, Cephalon, Inc.) for the treatment of CLL. Significant benefit has been demonstrated as first-line treatment with bendamustine achieving an overall response rate of 58% (n = 153) compared to a response rate of 26% (n = 148) with chlorambucil. Bendamustine is dosed at 100mg/m2 IV over 30 minutes on days 1 and 2 of a 28-day cycle, up to 6 cycles. For further information, click here: CLL Bendamustine

Lymphoma:

• According to the NCI, researchers have identified the gene, CARD11, as having a role in promoting activated B-Cell like diffuse large B-cell (ABC DLBC) lymphoma. This is finding is significant in that it provides a target for future drugs to be developed. For more information, click here: ABC DLBC Lymphoma and the CARD11 Gene

Multiple Sclerosis:

• According to the New England Journal of Medicine, use of rituximab has shown promise as a targeted therapy for relapsing-remitting multiple sclerosis. It is believed that B-cells are involved in the pathogenesis of multiple sclerosis, and rituximab is a monoclonal body that targets CD20 + B lymphocytes. For more information, click here: NEJM Multiple Sclerosis & Rituximab

Renal Cancer:

• Everolimus, an mTOR inhibitor, has demonstrated benefit in progression free survival for patients with advanced renal carcinoma who have progressed on the kinase-inhibitors sorafenib (Nexavar^®, Bayer Healthcare & Onyx Pharmaceuticals) and sunitinib (Sutent^®, Pfizer Inc.). For more information, click here: NCI Everolimus

Rheumatoid Arthritis and Neoplasms:

• Treatments for rheumatoid arthritis, especially cyclophosphamide, have been linked to increased occurrence of hematologic malignancies according to the Archives of Internal Medicine. For more information, click here: Rheumatoid arthritis

Articles of Interest
Chemotherapy Members May Enjoy These Recently Published Articles

Check out the Oncology Nursing Forum (ONF) and the Clinical Journal of Oncology Nursing (CJON) for interesting articles about chemotherapy.

• “The AIM Higher Initiative: New Procedures Implemented for Assessment, Information, and Management of Chemotherapy Toxicities in Community Oncology Clinics,” by Kelley Moore, RN, Gina Johnson, MSN, APRN-BC, Barry V. Fortner, PhD and Arthur C. Houts, PhD (CJON, Vol. 12, 229-238)
• “Evaluation and Management of Peripheral Neuropathy in Diabetic Patients With Cancer le,” by Constance Visovsky, PhD, RN, ACNP, Rachel R. Meyer, Jeffre Roller and Megan Poppas, BSN (CJON, Vol. 12, 243-247)
• “Intraperitoneal Chemotherapy for Women With Ovarian Cancer: Nursing Care and Considerations,” by Kamala L. Potter, RN, MS, AOCNS^® and Jeanne Held-Warmkessel, RN, MSN, APRN, BC, AOCN^® (CJON, Vol. 12, pp.265-271)
• “Effects of Exercise in Combination With Epoetin Alfa During High-Dose Chemotherapy and Autologous Peripheral Blood Stem Cell Transplantation for Multiple Myeloma,” by Elizabeth A. Coleman, PhD, RNP, AOCN^®, Sharon K. Coon, PhD, RN, AOCN^®, Robert L. Kennedy, PhD, Kimberly D. Lockhart, BS, Carol B. Stewart, BS, Elias J. Anaissie, MD and Bart Barlogie, MD, PhD (ONF, Vol. 35, E53-E61)

The SIGs Virtual Community Keeps You Connected

Jenny Shinsky
Pittsburgh, PA
jshinsky@ons.org

The SIGs Virtual Community was developed to improve
communication among SIG leaders and members. Visiting your SIG’s Web page on the Virtual Community keeps you updated about SIG activities by providing you with important information and resources.

To navigate to your SIG’s page, visit the SIGs Virtual Community at http://sig.vc.ons.org and select “Find a SIG” from the top navigation.

Many features in the SIGs Virtual Community are useful to all members. Below is an outline of the information that can be found on your SIG’s page.

From your SIG’s main page, you can subscribe to SIG announcements, calendar events, and the discussion forum. Once you are subscribed to the areas, an e-mail will be sent to you every time an announcement, event, or discussion has been posted.

Announcements are added frequently with important information pertaining to your SIG, such as scholarship, leadership, and meeting information.

SIG events on the SIG calendar are showcased on the main page for your convenience. Simply click on an event for detailed information.

About Us
The About Us area features information about your SIG leaders.

News
The News section provides important information, such as minutes from past meetings and newsletters. Educational news and photos also can be found here.

Discussions
Click the Discussions button at the top of your SIG’s page to access the area. You can post a message, thought, or questions and fellow SIG members can read your message and respond.

ONS National Announcements
Check this section every month for updated information from ONS such as continuing nursing education offerings, events, and important information.

Membership Information

SIG Membership Benefits

• Network with colleagues in an identified subspecialty area around the country.
• Contribute articles for your SIG’s newsletter.
• Participate in discussions with other SIG members.
• Contribute to the future path of the SIG.
• Share your expertise.
• Support and/or mentor a colleague.
• Receive information about the latest advancements in treatments, clinical trials, etc.
• Participate in ONS leadership by running for SIG coordinator-elect or join SIG work groups.
• Acquire information with a click of a mouse at http://ons.org/membership including
• Educational opportunities for your subspecialty
• Education material on practice
• Calls to action
• News impacting or affecting your specific SIG
• Newsletters
• Communiqués
• Meeting minutes.

Join a Virtual Community

A great way to stay connected to your SIG is to join its Virtual Community. It’s easy to do so. All you will need to do is

• Log on to the ONS Web site (http://www.ons.org/).
• Select "Membership" from the tabs above.
• Then, click on "ONS Chapters and Special Interest Groups."
• Scroll down to "Visit the ONS Special Interest Groups (SIG) Virtual Community" and click.
• Now, select "Find a SIG."
• Locate and click on the name of your SIG from the list of all ONS SIGs displayed.
• Once the front page of your SIG’s Virtual Community appears on screen, select "New User" from the top left. (This allows you to create log-in credentials.)
• Type the required information into the text fields as prompted.
• Click "Join Group" (at the bottom right of the text fields) when done.
  
  Special Notices
  
  
• If you already have log-in credentials generated from the ONS Web site, use this information instead of attempting to generate new information.
• If you created log-in credentials for the ONS Web site and wish to have different log-in information, you will not be able to use the same e-mail address to generate your new credentials. Instead, use an alternate e-mail address.

Subscribe to Your SIG’s Virtual Community Discussion Forum

All members are encouraged to participate in their SIG’s discussion forum. This area affords the opportunity for exchange of information between members and nonmembers on topics specific to all oncology subspecialties. Once you have your log-in credentials, you are ready to subscribe to your SIG’s Virtual Community discussion forum. To do so,

• Select "Log In," located next to "New User," and enter your information.
• Next, click on the "Discussion" tab on the top right of the title bar.
• Now, select "Featured Discussion" from the left drop-down menu.
• Locate and select "Subscribe to Discussion" inside the "Featured Discussion" section.
• Go to "Subscription Options" and select "Options."
• When you have selected and entered all required criteria, you will receive a confirmation message.
• Click "Finish."
• You are now ready to begin participating in your SIG’s discussion forum.

Participate in Your SIG’s Virtual Community Discussion Forum

• First, log in. (This allows others to identify you and enables you to receive notification [via e-mail] each time a response or new topic is posted.)
• Click on "Discussion" from the top title bar.
• Select "Featured Discussion" from the left drop-down menu.
• Click on any posted topic to view contents and post responses.

Sign Up to Receive Your SIG’s Virtual Community Announcements

As an added feature, members also are able to register to receive their SIG’s announcements by e-mail.

• From your SIG’s Virtual Community page, locate the "Sign Up Here to Receive Your SIG’s Announcements" section. This appears above the posted announcements section.
• Select the "Click Here" feature, which will take you to a link to subscribe.
• Once the "For Announcement Subscription Only" page appears on select how you wish to receive your announcements.
• As individual e-mails each time a new announcement is posted
• One e-mail per day comprised of all new daily announcements posted
• Opt-out, indicating that you will frequently browse your SIG’s Virtual Community page for new postings
• Enter your e-mail address.
• Click on "Next Page."
• Because you have already joined your SIG’s Virtual Community, you will receive a security prompt with your registered user name already listed. Enter your password at this prompt and click "Finish."
• This will bring up a listing of your SIG’s posted announcements. Click on "My SIG’s Page" to view all postings in their entirety or to conclude the registration process and begin browsing.

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ONS Membership/Leadership Team Contact Information

Angie Stengel, MS, CAE, Director of Membership/Leadership
astengel@ons.org
412-859-6244

Diane Scheuring, MBA, CMP, Manager of Member Services
dscheuring@ons.org
412-859-6256

Carol DeMarco, Membership/Leadership Administrative Assistant
cdemarco@ons.org
412-859-6230

The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability.

Oncology Nursing Society
125 Enterprise Dr.
Pittsburgh, PA 15275-1214
866-257-4ONS
412-859-6100
www.ons.org