Volume 14, Issue 1, February 2003  

What’s inside . . .

Coordinator’s Corner

Clinical Spotlight on Wendy J. Smith

Highlights From Recent Conferences

Nurse Reinvestment Act Passes

Advanced Practice Nurse Virtual Community Is Here

Managing Syndrome of Inappropriate Antidiuretic Hormone

Third Annual Advanced Practice Nurse Retreat

Manage Pain With Methadone

Save These Dates!

SIG Officers    Click here to print this newsletter

Coordinator’s Corner
Nurse Practitioner SIG Looks Forward to Activities in 2003

Terri Armstrong, MS, APRN, BC
Houston, TX

Another year is behind us, and I hope that everyone had a great holiday season. In 2002, we accomplished many things for our SIG and its members. Nurse Practitioner (NP) SIG members continue to be involved in ONS, from participating in the ONS Third Annual Institutes of Learning and the Advanced Practice Nurse (APN) Retreat to running for ONS president-elect. Kudos to all of you who continue to be involved and represent NPs in ONS. Please contact me with any awards or accolades you have received so that we can share this with the SIG (see SIG Officers page for all contact information).

This issue is full of information, from a review of syndrome of inappropriate antidiuretic hormone to information on results of studies presented at annual meetings to our member highlight section. I encourage all of you to consider submitting material to the newsletter.

You also may want to check out the APN Virtual Community and NP SIG Virtual Community on ONS Online. You will find information on current conferences, legislative issues, job descriptions, and other helpful information.

ONS has decided to provide one SIG membership free of charge. What a wonderful gift! I hope that you all continue your membership in the NP SIG through this offer and encourage your oncology NP colleagues to consider joining our group. Please contact me with any issues or concerns.

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The ONS Nurse Practitioner SIG Newsletter
is underwritten through a grant from Amgen, Inc.

Special Interest Group Newsletter  February 2003

Clinical Spotlight
Wendy J. Smith Is Involved in Many Ways in Oncology Advanced Practice Nursing

Janet Van Cleave, MSN, ACNP-CS, AOCN®
New York, NY

Wendy J. Smith, MSN, ACNP, AOCN®, author of “Passage of the Nurse Reinvestment Act: We Have Much to Celebrate and Much Work to Do,” is currently a nurse practitioner in an outpatient setting at West Clinic in Memphis, TN. She sees patients for scheduled and unscheduled office visits, manages patients who are receiving chemotherapy, and attends to any chemotherapy-related problems such as reactions. From August 1995 to July 2002, she worked for the North Mississippi Hematology and Oncology Associates, Ltd., in Tupelo, where her practice was in a rural setting and her role involved covering the satellite clinics on days without physician coverage. This involved seeing patients who had scheduled routine appointments, unscheduled patients with problems, and patients receiving chemotherapy who experienced chemotherapy-related problems. As part of her responsibilities, she also saw the new patient consults at an affiliated hospital, performed history and physical examinations, initiated workups, and followed patients during their hospitalizations.

Wendy began her nursing career as a diploma graduate from the School of Nursing at St. Luke’s Hospital in Bethlehem, PA. She returned to school at Cedar Crest College in Allentown, PA, where she graduated cum laude with her bachelor of science of nursing. She received her master of science in nursing as an acute care nurse practitioner from the University of Alabama at Birmingham. During her graduate education, Wendy’s clinical rotations were at the University of Alabama at Birmingham and the University of Texas M.D. Anderson Cancer Center in Houston.

Wendy was the first nurse practitioner in Mississippi to specialize in oncology and has worked closely with the Mississippi Board of Nursing and Mississippi Nurses Association, especially in regard to nurse practitioner and advanced practice nursing issues. Because of Wendy’s involvement in advocacy, legislation has been passed changing state practice laws to allow Mississippi nurse practitioners to prescribe controlled substances.

Wendy is involved extensively in ONS. She has supported the Nurse Practitioner SIG through her leadership in the practice, reimbursement, and legislative network. Her many other activities in ONS include participating in the Leadership Development Institute, reviewing articles for the Clinical Journal of Oncology Nursing from 1999–2002, and serving as the ONS Health Policy Liaison for Mississippi. She has given many presentations at national meetings about topics pertinent to nurse practitioners, including diagnostic procedures at the ONS 24th Annual Congress in 1999 and the Acute Care Nurse Practitioner Certification Preperation Course at the 1999 American Association of Critical Care Nurses’ National Teaching Institute. She is a trainer for ONS’s biotherapy and chemotherapy course and project team coordinator for six regional health policy advocacy workshops across the United States on legislative advocacy skills. Wendy has contributed to the profession through publications. She wrote five chapters for the Clinical Manual for the Oncology Advanced Practice Nurse, edited by Dawn Camp-Sorrell, RN, MSN, FNP, AOCN®, and Rebecca Hawkins, RN, MSN, ANP, AOCN®.

Wendy’s work has significantly affected the development of the oncology nurse practitioner role, and she is a great resource regarding the practice of oncology nurse practitioners or legislative advocacy in oncology. If you have any questions for Wendy, you can contact her at wsmith@afo.net.

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Special Interest Group Newsletter  February 2003

Recent Oncology Conferences Included Advanced Practice Nursing Issues

Janet Van Cleave, MSN, ACNP-CS, AOCN®
New York, NY

In the past few months, several conferences have been held that are of interest to advanced practice oncology nurses. Below are some highlights from these conferences.

American Society for Therapeutic Radiology and Oncology 44th Annual Meeting
The annual meeting of the American Society for Therapeutic Radiology and Oncology (ASTRO) was held in New Orleans, LA, on October 6–10, 2002. One of the highlights of the meeting was the plenary session for the top five proffered papers. Below are the titles of these abstracts, the primary authors, and the authors’ conclusions. For more information about this meeting and ASTRO, visit ASTRO's Web site at www.astro.org.

  • Pelvic radiation with concurrent chemotherapy versus pelvic and para-aortic radiation for high-risk cervical cancer: An update of RTOG 90-01. Eifel, P.J., et al. The authors concluded that the addition of 5-fluorouracil and cisplatin to radiation therapy significantly improved the survival rate of women with locally advanced cervical cancer, decreasing local and distant recurrences without significantly increasing the rate of sequelae from treatment.
  • Screening mammography is associated with earlier stage disease and greater eligibility for breast conservation in women aged 40 and older with breast cancer. Feedman, G.M., et al. The authors concluded that women aged 40 or older who underwent mammography at least annually were more often diagnosed with noninvasive stage 0 breast cancer compared with women who had less frequent screening. Also, women who had any history of mammography prior to the time of diagnosis of invasive disease presented with earlier stage and smaller tumor size. Thus, a history of prior mammography appears to be linked to greater eligibility for breast conservation surgery and less frequent recommendations for mastectomy.
  • Patterns of failure for resected advanced head and neck cancer treated by concurrent chemotherapy and radiation therapy: An analysis of RTOG 9501/intergroup phase III trial. Cooper, J.S., et al. The authors found that concurrent, single-agent cisplatin chemotherapy with postoperative radiation therapy (without any subsequent adjuvant chemotherapy) decreases locoregional recurrence as the first evidence of treatment failure and decreases distant recurrence to almost the same degree. However, overall survival was not improved.
  • Larynx preservation and tumor control in stage III and IV laryngeal cancer: A three-arm randomized intergroup trial; RTOG 91-11. Maor, M.H., et al. Concomitant chemotherapy and radiotherapy was superior for laryngectomy preservation rate and locoregional control compared with induction chemotherapy followed by radiotherapy and radiotherapy alone. Patients on the concomitant treatment arm had a superior laryngectomy-free survival compared to patients treated with radiation alone. However, better local control with the concomitant treatment arm did not improve survival.
  • Stereotactic radiosurgery with whole brain radiation therapy improves survival in patients with brain metastases: Report of radiation therapy oncology group phase III study 95-08. Sperduto, P.W., et al. Whole brain radiation therapy (WBRT) plus stereotactic radiosurgery (SRS) provided a survival advantage compared to whole brain radiation therapy alone in each of the following categories: (a) solitary brain metastasis, (b) recursive partitioning analysis class I, (c) age less than 50, and (d) non-small cell lung cancer or any squamous cell carcinoma. Furthermore, all subsets of patients with WBRT plus SRS were more likely to have a stable or improved performance than those with WBRT alone at three and six months. No significant difference existed in cause of death, but significant difference did exist in local control. Toxicities were comparable between the two groups.
ONS Third Annual Institutes of Learning
ONS held its Third Annual Institutes of Learning on November 1–3, 2002, in Seattle, WA. The institutes included information on genetics, palliative care, cancer clinical trials, combined therapies, gynecologic cancer, coagulopathies, and new trends in technology. Regina S. Cunningham, RN, MA, AOCN®, and Deborah A. Boyle, RN, MS, AOCN®, coordinated a session discussing outcome measurement in advanced practice nursing. The daylong session provided an overview on the state of the knowledge of advanced practice nursing outcomes and discussed approaches to quantifying and documenting the outcomes of advanced practice nursing in the clinical oncology setting. The coordinators provided time for advanced practice nurses to share experiences, practical approaches, and recommendations regarding the documentation of advanced practice nursing outcomes. The session ended with advanced practice nurses discussing possible projects in their workplaces.

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Special Interest Group Newsletter  February 2003

Passage of the Nurse Reinvestment Act:
We Have Much to Celebrate and Much Work to Do

Wendy J. Smith, MSN, ACNP, AOCN®
Baldwyn, MS

I didn’t hear about it on the national news or read about it in my local newspaper, but on July 22, 2002, a historical event occurred when the Nurse Reinvestment Act quietly passed through the House of Representatives and the Senate. ONS worked very hard to push for this, so we, as members, have much to celebrate. Our efforts during Hill Day at the ONS 27th Annual Congress, as well as the ongoing efforts of our leadership; Ilisa Halpern, ONS’s health policy associate in Washington, DC; and other nursing organizations influenced the passage of this bill. Following are a few of the issues this bill addressed.
  • Public service announcements to promote the nursing profession
  • Support for scholarships for nursing students who agree to work for a period of time at institutions facing a shortage of nurses
  • Cancellation of student loans for nurses seeking advanced degrees and agreeing to teach at schools of nursing
  • Grants for hospitals and medical facilities that provide incentives for nurses to advance in their field
The passage of this bill is so exciting, but we cannot afford to sit back and rest. Although this bill has passed, funding for these programs was not part of the package; we must fight for the needed funds. Please contact your representatives and senators and request that they not only support funding efforts but also push for funding. In addition, we need to focus on new efforts to get nurses out of the “zero work pool.” In other words, we need to launch new efforts that will result in nurses being reimbursed for what they do. Please be vocal and active in health policy advocacy. We can make a difference. We have already.

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Special Interest Group Newsletter  February 2003

Advanced Practice Nurse Virtual Community Now Is Available

Mary Pat Lynch, CRNP, MSN, AOCN®
2001 Advanced Practice Nurse Retreat Team Leader
Haverford, PA

The 2001 Advanced Practice Nurse (APN) Retreat Team is finishing up its yearlong project that began at the retreat in Palm Beach, FL, in November 2001. The APNs who were selected to attend this retreat, funded by the ONS Foundation and Aventis Pharmaceuticals, were divided into five project teams. Each team focused on a different area of importance to APNs practicing in oncology today. These areas included Standards of APN Practice, APN Outcomes, Online Education for APNs, Legislative and Reimbursement, and Evidence-Based Practice. Each team had its own objectives and projects to complete.

ONS APNs now are able to benefit from the work of these teams. The APN Retreat team has developed a virtual community for APNs on ONS Online. This community now is available and open to all ONS APNs. Content of the community includes
  • Vital reimbursement information and resources
  • Key online resources, Web sites, and continuing education for APNs
  • Practical information about outcomes research
  • A preview of updated APN standards documents
  • Links to evidence-based practice resources.
The APN Virtual Community promises to be a timely resource for oncology APNs and is available now at http://apn.ons.wego.net.

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Special Interest Group Newsletter  February 2003

Learn More About Syndrome of Inappropriate Antidiuretic Hormone

Geline Joy Tamayo, RN, MSN, CS
Houston, TX

Hyponatremia associated with normal or excess extracellular fluid volume is syndrome of inappropriate antidiuretic hormone (SIADH). The first clinical case was reported in 1957 and involved two patients with lung cancer who developed hyponatremia with normal renal function. Researchers postulated that tumors led to inappropriate release of antidiuretic hormone (ADH) or ADH-like substance. In hospitalized patients, the most common cause of hyponatremia are malignancy, pulmonary disorders, or central nervous system disorders. This article will discuss the incidence, physiology, pathophysiology, causes, symptoms, evaluation, treatment, and nursing management of SIADH.

The classic tumor type associated with SIADH is small cell lung cancer (SCLC), and 11%–15% of patients with SCLC manifest the disorder. Other tumors with which SIADH may occur are non-small cell lung cancer (NSCLC) and head and neck cancer. Isolated case reports have documented the occurrence of SIADH in other malignancies, including metastatic breast cancer and brain tumors.

The renal and endocrine systems regulate the osmolality of body fluids.

Renal: One important function of the kidneys is osmoregulation. A low osmolality (less than 285 mOsm/l) triggers a nervous and hormonal feedback mechanism, causing the kidneys to excrete large amounts of water in urine. Removal of water from the body increases the body osmolality, bringing it back to normal. Conversely, high osmolality allows the kidneys to continue excreting large amounts of solutes (sodium, chlorine, and potassium), increasing reabsorption of water intracellularly and resulting in a low osmolality.

Endocrine: ADH is the hormone that signals the kidneys to excrete concentrated urine. This hormone is an integral part of the homeostatic mechanism that controls water balance and effective blood volume. ADH is produced in the hypothalamus and released from the posterior pituitary gland in response to decreased osmolality. The hormone acts specifically on the distal tubular segments of the collecting duct system. ADH’s major
physiologic action is to regulate water reabsorption under the osmotic influence of the hypertonic renal medulla by increasing permeability of water in the renal tubules. Excess production of ADH results in water retention and moderate expansion of plasma volume.

SIADH is classified as an endocrine paraneoplastic syndrome. The syndrome is caused by an abnormal secretion of an endocrine peptide unrelated to invasion by the primary tumor or malignancy. SIADH is a result of inappropriate production and secretion of ADH, also known as arginine vasopressin (AVP).

Secretion of AVP occurs in response to plasma hyperosmolality or to hypovolemia. Excess secretion of AVP increases water retention and causes hyponatremia. Secondary stimulation of ADH occurs by three mechanisms: (a) ADH is synthesized and autonomously released from tumors, (b) nontumorous tissue synthesizes and releases ADH autonomously, and (c) ADH is released from the pituitary gland inappropriately secondary to inflammation, neoplasm, vascular lesions, or drugs.

SIADH occurs as a result of multiple causes, including malignancies (lung, lymphoma, and leukemia), endogenous causes (central nervous system disorders, pulmonary conditions, and postoperative period), and pharmacologic agents, as well as other miscellaneous causes (head trauma, intracranial hemorrhage, and positive pressure
ventilation). Pharmacologic agents causing SIADH include chemotherapeutic agents (cyclophosphamide, vincristine, vinblastine, cisplatin, and melphalan), analgesics (acetaminophen and opioids), antidepressants (tricyclics and selective serotonin reuptake inhibitors), and other medications (azithromycin, barbiturates, carbamazepine, chlorpropramide, clofibrate, isoproterenol, nicotine, and thiazides).

Signs and Symptoms
Signs and symptoms are a result of hyponatremia and can range from patients being asymptomatic to more profound signs. Profound signs are a result of the magnitude of hyponatremia (sodium less than 110 mEq/l) as well as acuity of drop in serum sodium (occurs in 48 hours or less). Mild symptoms may occur when the serum sodium level ranges from 125–134 mEq/l, but patients also may be asymptomatic. If symptoms occur, they are relatively nonspecific and commonly seen in patients with cancer. These symptoms include anorexia, difficulty concentrating, fatigue, headache, weakness, muscle cramps, and weight gain.

Moderate symptoms may be seen when the serum sodium level is 116–124 mEq/l. These include confusion, depressed deep tendon reflexes, impaired taste, thirst, incontinence, lethargy, nausea and vomiting, diarrhea, oliguria, and personality changes.
Severe symptoms may occur when serum sodium is less than 115 mEq/l and include seizures and coma.

Clinical features of SIADH include isovolemia, hypotonic, and hyponatremic conditions. The hallmark for SIADH is hyponatremia, but this also can occur in hypovolemia and hypervolemia. If hypovolemia and hypervolemia are present, other medical conditions need to be considered.

In diagnosing SIADH, absolute findings are necessary; patients may be asymptomatic, but laboratory tests are useful in early identification. In evaluating hyponatremia, clinicians should obtain patients’ history of presenting symptoms with a description of onset, location, and duration of precipitating factors. Clinicians should note any changes in activities of daily living and review fluid intake and output in the past 24 hours. Past medical history should include a history of cancer or any chemotherapy treatment. Other important information includes current medications (both prescribed and over-the-counter) as well as any herbs or vitamins.

Clinicians should review laboratory tests for early identification (see Table 1). The important laboratory findings include low uric acid and normal to decreased blood urea nitrogen or creatinine as a result of increased glomerular filtration.

Isovolemia is an absolute criterion. Clinically, patients show no evidence of edema or congestive heart failure. In SIADH, patients are not associated with hypovolemia or hypotension.

The goal is correction of the serum sodium level to normal. In evaluating the appropriate treatment for SIADH, previous serum sodium levels should be reviewed. Important questions that will guide therapy are whether this is an acute development of hyponatremia (developing over hours to two days) or whether the hyponatremia is chronic in nature (evolves over 48 hours). If the presentation is acute and significant neurologic symptoms such as seizures are present or the patient is comatose, rapid correction is justified. Presence of life-threatening hyponatremia requires aggressive therapy with hypertonic (3%) saline infusions and IV loop diuretics such as furosemide (thiazides are not recommended). An important guideline is that once the sodium level has reached 125 mEq/l, active treatment should be stopped. Initial correction should not exceed 0.5 mEq/l per hour, final correction in the range of 10–15 mEq/l in 24 hours. Serious neurologic complications occur with rapid correction, known as osmotic demyelination syndrome (central pontine myelinolysis).

If laboratory values show that the hyponatremia is chronic, slow correction is indicated. Decrease of malignant disease and tumor regression correlates with prompt resolution of SIADH. Therefore, the primary therapy of SIADH is treatment of the underlying malignancy with multiagent chemotherapy, radiation, or corticosteroids. Medications that can cause hyponatremia, such as chemotherapeutic agents, antidepressants, analgesics, diuretics, and carbamazepine, as well as medications that stimulate ADH release, should be avoided.

Other methods to treat or control SIADH when treatment of the underlying malignancy is not possible are oral fluid restriction, pharmacologic agents, and IV fluids. Oral fluid restriction (500–1,000 ml per 24 hours) effectively elevates plasma sodium in three to five days. If this does not work, demeclocycline, a tetracycline derivative, inhibits the action of ADH on renal tubules, decreasing water reabsorption and excreting water. The recommended dose is 600–1,200 mg per day in divided doses (available in 300 mg tablets). Compliance may be an issue; therefore, patients can take demeclocycline either two or four times a day. The medication should be taken one to two hours before or after a meal. Concomitant administration with aluminum, magnesium, iron, or calcium products causes chelation and malabsorption of the drug and should be avoided. In doses of 1,200 mg per day, azotemia is a major risk, as some patients have reported photosensitivity and nausea. Fluid restriction is not necessary during treatment with demeclocycline. Results occur in three to five days and continue for several days after discontinuing the drug. Patients have been treated up to 16 months without any complications. Another drug that can be used is lithium carbonate (900–1,200 mg per day); however, lithium carbonate has more toxic potentials such as seizures, coma, and ventricular arrhythmias, and lithium levels must be monitored.

Nursing Management
Nursing plays a key role in the management of patients with SIADH. Nurses must understand the pathophysiology of the syndrome because definitive treatment eliminates the underlying cause of the disorder. Key actions by nurses include recognition of the signs and symptoms of SIADH with the understanding that some patients may be asymptomatic with low sodium levels. A careful review of the laboratory results of the patients and identification of the patients at risk (patients with SCLC and brain tumors), chemotherapeutic agents treating the malignancy, and patients’ other medications can help identify patients with SIADH before life-threatening emergencies occur.

Other important nursing interventions include
  1. Patient and family education. This can include basic information about SIADH and its causes, signs, and symptoms. If patients are under fluid restriction, patients and their family members should receive teaching in the desired daily intake in liquids and how to measure intake and output. This should include the general amount in milliliters of cups patients use frequently. Family members and patients also can be taught how to measure the amount of urine, use of urinals, and the recording of daily inputs and outputs at the bedside.
  2. Frequent neurologic assessment. A key component of the neurologic assessment is patients’ levels of consciousness and orientation. Any changes in their mental status should be reported to the primary clinician.
  3. Monitoring of vital signs every four hours. Increases in pulse, respirations, and blood pressure are typical.
  4. Fluid restriction. Fluid intake via any route is recorded as intake. Meticulous monitoring of inputs and outputs is necessary. Placement of a Foley catheter for those who are incontinent may be necessary to ensure accuracy of inputs and outputs. Medications should be scheduled with meals to provide maximum flexibility in fluid intake. If they are thirsty, patients can suck on candy. Tap water and saline enemas should be avoided to prevent absorption of water in the intestines. Nasogastric and enteral tubes should be irrigated with normal saline rather than water. Keep oral mucous membranes moist by providing frequent mouth care and do not use mouthwashes that contain alcohol.
  5. Seizure precautions. Patients with severe hyponatremia are at risk for seizures.
  6. Dietary needs. Encourage a diet high in sodium and protein to increase urine excretion.
  7. Evaluate for fluid retention. When fluid retention is suspected, monitoring of inputs and outputs, baseline weight, and daily weight is essential. Evaluate patients for edema in dependent areas. Assess their lungs to detect overhydration and monitor skin turgor.
Berl, T. (1994). Hyponatremia. In R.W. Schrier (Ed.), The internal medicine casebook (1st ed., pp. 390–395). Boston: Little Brown and Co.

Brantem, A.J., Koene, R.A., Weber, A.M., & Wetzels, J.F. (1998). Hyponatremia due to sodium valproate. Annals of Neurology, 43, 265–267.

Carlson, H.E. (2000). Metabolic complications. In D.A. Casciato & B.B. Lowitz (Eds.), Manual of clinical oncology (4th ed., pp. 526–543). Philadelphia: Lippincott.

Ezzone, S.A. (2000). Syndrome of inappropriate antidiuretic hormone. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (pp. 571–583). Pittsburgh, PA: Oncology Nursing Society.

Gagel, R.F., & Yeung, S.J. (2000). Endocrine complications. In J.F. Holland, E. Frei, III, R.C. Bast, Jr., D.W. Kufe, R.E. Pollock, & R.R. Weicheselbaum (Eds.), Cancer medicine (5th ed., pp. 1458–1467). Hamilton, Ontario, Canada: B.C. Decker.

Keenan, A.M. (1999). Syndrome of inappropriate secretion of antidiuretic hormone of malignancy. Seminars in Oncology Nursing, 15, 160–167.

Kirby, R.R., Civetta, J.M., & Taylor, R.W. (1997). Fluids and electrolytes. In Handbook of critical care (2nd ed., pp. 34–65). Philadelphia: Lippincott-Raven.

Kleta, R., Jurgens, H., & Wagner, A. (1998). Recurrence of SIADH after high-dose regimen of thiotepa, carboplatin and etoposide phosphate. Medical and Pediatric Oncology, 31, 129.

Mouallem, M., Ela, N., & Segal-Lieberman, G. (1998). Meningeal carcinomatosis and syndrome of inappropriate antidiuretic hormone in a patient with metastatic carcinoma of the stomach. Southern Medical Journal, 91, 1076–1078.

Schwartz, W.B., Bennett, W., Curelops, S., & Barter, F.C. (1957). A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. American Journal of Medicine, 23, 529–542.

Sorensen, J.B., Anderson, M.K., & Hansen, H.H. (1995). Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in malignant disease. Journal of Internal Medicine, 238, 97–110.

Terpstra, T.L., & Terpstra, T.L. (2000). Syndrome of inappropriate antidiuretic hormone secretion: Recognition and management. Medsurg Nursing, 9, 61–70.

Warrell, R.P., Jr. (2001). Metabolic emergencies. In V.T. DeVita, Jr., S. Hellman, & S.A. Rosenberg (Eds.), Cancer principles and practice (6th ed., pp. 2633–2645). Philadelphia: Lippincott.

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Special Interest Group Newsletter  February 2003

Third Annual Advanced Practice Nurse Retreat Focuses on Evidence-Based Practice

Diane Cope, PhD, ARNP-BC, AOCN®
Fort Myers, FL

The ONS Third Annual Advanced Practice Nurse (APN) Retreat, “Evidence-Based Practice: From Retreat to Reality,” was held November 15–17, 2002, in Pittsburgh, PA.
Planning team members included team leaders Terri Armstrong, MS, APRN, BC, and Martha Langhorne, MSN, RN, FNP, AOCN®; Diane Cope, PhD, ARNP-BC, AOCN®; Mary Cunningham, RN, MS, AOCN®; and ONS staff members Laura Fennimore, MSN, RN, Laurl Matey, MSN, RN, and Judy DePalma, PhD, RN. Dana Rutledge, PhD, RN, and Marilyn Bookbinder, PhD, RN, experts in the area of evidence-based practice, gave the keynote address, “Moving Towards Evidence-Based Practice.” Their presentations on the background, purpose, scientific need, process, and clinical examples of evidence-based practice provided a strong foundation for the 35 APN participants. Additional presentations given by Carrie Stricker, MSN, RN, CS, CRNP, AOCN®, Judy DePalma, Dana Rutledege, Mary Cunningham, and ONS Staff Librarian Mark Vrabel, MLS, AHIP, provided the actual “how-to” procedures to perform a literature search, critically appraise the literature and systematic reviews, and make practice change recommendations based on the evidence. Participants were given integrative reviews for oncology topics that included fatigue, nutrition, patient education, decision making, palliative care, pain, dyspnea, prevention and screening, and complementary therapies. Participants were asked to critically appraise the reviews and make practice recommendations.

The critiques and recommendations will be posted on the ONS Evidence-Based Practice Resource Center.

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Special Interest Group Newsletter  February 2003

How to Manage Cancer Pain Using Methadone

Shirley Missoul, RN
New York, NY

Janet Van Cleave, MSN, ACNP-CS, AOCN®
New York, NY

Opioids are one of the primary therapies for moderate to severe cancer pain management. In approximately 80% of patients with advanced cancer-related pain, one or more changes may be necessary in the type of opioid or the route of its administration to meet specific clinical goals such as improved pain control or reduced opioid toxicity. Preclinical studies demonstrate that opioids can act on different receptors or subtype receptors, and individual receptor profiles as well as genetic profiles may influence analgesia and adverse effects. Thus, individual reactions to opioids can vary (Mercadante et al., 2001). Methadone is a synthetic opioid agonist that can be used orally, rectally, and parenterally. It was developed more than 40 years ago and generally is used as maintenance therapy for people with opioid dependence (Bruera & Sweeney, 2002). Methadone has attracted attention since the 1990s as an attractive alternative to mu opioid analgesia because of its lack of neuroactive metabolites, clearance independent of kidney function, good oral availability, and low cost. The drug’s long half-life decreases the need for multiple daily doses. Another advantage of using methadone is that it has noncompetitive antagonist activity at the N-methyl-D-aspartate (NMDA) receptors, which gives it the potential to control pain unresponsive to other opioids (Mercadante et al.). However, these advantages also have complicated the use of methadone. The half-life can be unpredictable, resulting in accumulation and toxicity in some patients. In addition, the antagonist activity at the NMDA receptors makes rotation from a previous opioid to methadone more complex than with other opioids in patients who are opioid tolerant. Therefore, methadone remains a second-line opioid in cancer pain management (Bruera & Sweeney).

Learn More About Methadone:
Commentary on ‘How to Manage Cancer Pain Using Methadone’

As “How to Manage Cancer Pain Using Methadone” by Missoul and Van Cleave suggests, methadone is a very valuable agent for patients with cancer pain. Methadone is by far the cheapest potent opioid available, costing usually 10% of comparable agents used for chronic moderate to severe pain, such as sustained-release forms of morphine, oxycodone, or fentanyl. Moreover, its activity against the N-methyl-D-aspartate (NMDA) receptor, as well as its binding of the opioid receptor, gives it special efficacy in patients with chronic severe neuropathic pain who have increased numbers of NDMA receptors. Doses of methadone usually needed to control this type of pain are much lower than other opioids because, as Missoul and Van Cleave note, methadone binds opioid receptors and inactivates NDMA receptor-induced inhibition of opioid-induced analgesia. Another safe conversion strategy is to use 2 mg of oral or IV methadone for each 30 mg of oral morphine. If questions arise regarding these calculations, oncology clinicians always can consult with a pain or palliative care team.

Janet L. Abrahm, MD
Director of the Pain and Palliative Care Program at the Dana-Farber Cancer Institute in Boston, MA
Recent studies investigated the appropriate equianalgesic dose ratio between morphine and methadone and the efficacy of methadone. Ripamonti et al. (1998) evaluated patients who changed from morphine to methadone to define the dose ratio between the two drugs. In a prospective study of 38 consecutive patients with cancer, the researchers found that a median time of three days was necessary for patients to have the same pain relief from methadone that they were experiencing with the morphine sulfate. In addition, they found that the lower the preswitching oral morphine dose, the fewer days were needed to achieve the same pain relief with oral methodone. The dose ratios ranged from 2.5–14.3, demonstrating that in most cases the dose ratio was much higher than suggested by published equianalgesic tables and that the dose ratio is not constant but increases in accordance with increasing morphine doses. The final median dose ratios found to produce equianalgesia with morphine were 3.7:1 for patients who received 30–90 mg daily of morphine, 7.75:1 for those who received 90–300 mg daily, and 12.25:1 for patients who received more than 300 mg daily.

Using an equianalgesic dosing schedule of 1:4 for less than 90 mg morphine sulfate, 1:8 for 90–300 mg, and 1:12 for patients receiving more than 300 mg, Mercadante et al. (2001) evaluated the clinical benefit in opioid rotation from morphine to methadone. Symptom distress, intensity of pain, and adverse effects were assessed daily in 52 consecutive patients with cancer who were experiencing poor analgesia or adverse effects from morphine and changed to methadone. Data were analyzed for 50 patients. In the 10 patients who were switched to methadone because of uncontrolled pain, a significant reduction in pain intensity and symptom distress was seen in an average of 3.5 days with a 33% increase in methadone doses. In the 32 patients who were switched to methadone because of uncontrolled pain and morphine-related side effects, a significant improvement occurred, revealed by decreased pain intensity, nausea and vomiting, constipation, and drowsiness with an average 20% dose increase.

These studies suggest that methadone is a valid therapeutic option in patients who are experiencing poor pain control or adverse effects. However, determining the appropriate dose and schedule can be complex. Therefore, the recommendation from the literature advises consulting a pain management team when considering using methadone in cancer pain management (Abrahm, 2000).

Abrahm, J. (2000). Pain management in patients with advanced cancer [Comment on]. Annals of Internal Medicine, 132, 593.

Bruera, E., & Sweeney, C. (2002). Methadone use in cancer patients with pain: A review. Journal of Palliative Medicine, 5, 127–138.

Mercadante, S., Casuccio, A., Fulfaro, F., Groff, L., Boffi, R., Villari, P., et al. (2001). Switching from morphine to methadone to improve analgesia and tolerability in cancer patients: A prospective study. Journal of Clinical Oncology, 19, 2898–2904

Ripamonti, C., Groff, L., Brunelli, C., Polastri, D., Stavrakis, A., & DeConno, F. (1998). Switching from morphine to oral methadone in treating cancer pain: What is the equianalgesic dose ratio? Journal of Clinical Oncology, 16, 3216–3221.

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Special Interest Group Newsletter  February 2003

Save These Dates!

Mark Your Calendars for SIG’s Special Congress Symposium
The Nurse Practitioner SIG’s 2001 Advanced Practice Nurse Retreat Team will cosponsor a special evening symposium at the ONS 28th Annual Congress in Denver, CO, on Thursday, May 1, immediately following our SIG’s planning meeting. The featured speaker is Carolyn Bupper, JD, CRNP, a nationally known expert on nurse practitioner practice, who will discuss advanced practice nursing reimbursement and collaborative practice. Further information about the session and how to register will be announced through e-mail and Congress information packets. We hope to see many of you there!

What Is Your Role in the Genetics Revolution?
Are you ready for the genetics revolution? Do you understand how cancer and genetics are related? Can you provide accurate information for your patients regarding genetic risk for cancer or the use of gene therapy as a cancer treatment? Do you want to include a genetic question, focus, or outcome in your research and education efforts?

If you answered yes to any of these questions, register today for the Cancer Genetics Revolution Research Short Course, a unique program designed to increase your knowledge base of this cutting-edge field. ONS is accepting applications from master’s- and doctorally prepared oncology nurses who feel that the genetics revolution is happening without them.

Courses will be held March 28–30 in Pittsburgh, PA, and May 3–5, in Denver, CO (following the ONS annual Congress). For more information, visit the Genetics Short Course Web site.

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Special Interest Group Newsletter  February 2003

Nurse Practitioner SIG Officers

Terri Armstrong, MS, APRN, BC
2908 Amherst St.
Houston, TX 77005-3018
713-665-0718 (H)
713-745-4621 (O)

Diane Cope, PhD, ARNP-BC, AOCN®
605 Astarias Circle
Fort Myers, FL 33919-3247
239-437-3571 (H)
239-437-4444 (O)

Janet Van Cleave, MSN, ACNP-CS, AOCN®
11 E. 87th St., Apt. 8A
New York, NY 10128
212-289-7849 (H)
917-738-5474 (O)
Christie Hancock, APN, MSN, RN, OCN®
224 E. Jackson
Jonesboro, AR 72401
870-935-4546 (H)
870-972-4510 (O)

ONS Publishing Division Staff
Elisa Becze, BA
Copy Editor

Know someone who would like to receive a print copy of this newsletter?
To print a copy of this newsletter from your home or office computer, click here or on the printer icon located on the SIG Newsletter front page. Print copies of each online SIG newsletter also are available through the ONS National Office. To have a copy mailed to you or another SIG member, contact Membership/Leadership Administrative Assistant Carol DeMarco at carol@ons.org or 866-257-4ONS, ext. 6230.

ONS Membership/Leadership Team Contact Information
Angie Stengel, Director of Membership/Leadership

Diedrea White, Manager of Member Relations

Carol DeMarco, Membership/Leadership Administrative Assistant

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
ONS Online: www.ons.org

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