Volume 15, Issue 1, March 2004   
The ONS Nurse Practitioner SIG Newsletter is underwritten through a grant from Amgen, Inc.
Coordinator's Corner
Get Involved With the Nurse Practitioner SIG

Diane G. Cope, PhD, ARNP, BC, AOCN®
Fort Myers, FL

Now that we have had the time to break the New Year’s resolutions that we made in January, I propose that we add another to the top of our lists: Get involved with the Nurse Practitioner (NP) SIG. Each and every one of you has so much to offer. Plus, the rewards of participation are so numerous.

This newsletter features two areas that you could consider: legislation and newsletter article authorship. Wendy Vogel, MSN, FNP, AOCN®, discusses numerous simple opportunities to get involved with legislation and make your voices heard among policymakers. More importantly, Wendy emphasizes reasons why we, as nurses, must be involved.

The editors of the NP SIG newsletter also have placed a call for articles in this issue. You should not view writing as a major hurdle; you have so many interesting things happening in your work setting that could be shared with everyone. Also, writing a new drug update is simple and so valuable for all of the members.

In addition to these two areas, you also might want to become involved in the NP SIG Mentor/Mentee program. The program now has 29 mentor/mentee groups. We always can use more mentors, and it is extremely rewarding to work with a new NP.

I hope that you will strongly consider getting involved. We want and need your participation! I am looking forward to seeing you at the ONS 29th Annual Congress. Two NP SIG-sponsored sessions will be presented. They are “Management of Medical Problems in the Oncology Patient” (pre-Congress session) and “Change Can Be Good for Your Patients: An Interactive Workshop on Opioid Rotation” (instructional session). Hope to see you and hope to hear from you to get involved!


Special Interest Group Newsletter  March 2004

Write for the Nurse Practitioner SIG Newsletter in 2004

The Nurse Practitioner SIG Newsletter is sending out a call for articles for 2004. Whether you are widely published or would like to be published for the first time, we need you! If you would like to write something for our newsletter in 2004, our deadlines are May 20 and September 22. If you have questions or need any ideas or inspiration, please contact Editor Janet VanCleave, MSN, ACNP-CS, AOCN®, or Coeditor Christie Hancock, APN, MSN, RN, CS, OCN® (see SIG Officers page for all contact information).

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Special Interest Group Newsletter  March 2004

Visit the SIG Virtual Community Today

Bridget A. Cahill, APN, NP-C
Chicago, IL

Are you having difficulty accessing the Nurse Practitioner (NP) SIG Virtual Community? Here are some helpful steps so you won’t miss this important Web site! To access the site, go to www.ons.org. Find “Virtual Communities” on the left side under quick links and click. Go to ONS Virtual Communities and click on “ONS Special Interest Groups Virtual Community.” Go to “Find a SIG” at the top right hand corner and click. Find the list of SIGs and select “Nurse Practitioner.” You will find a wealth of information for NPs on this Web site.

The Web site offers general information regarding ONS and information specific to NPs. General announcements for ONS and featured ONS events are available.

The information includes documents such as an NP job description, resources such as Standards of Oncology Advanced Practice Nurses (APNs), reimbursement topics, online education, and APN outcomes that provide ways for and encourage APNs to become involved in outcomes research. NP SIG upcoming events are found on this Web site, as well as notes from the NP SIG coordinator. NP SIG favorites include ONS bylaws, a link to the American Academy of NPs’ Web site, and billing for NP services.

Also included is a discussion forum to ask questions to the members of the NP SIG, a calendar of upcoming events, the NP SIG mission statement and strategic plan, and leadership contact information. You also may access the SIGnal newsletter and the quarterly NP SIG Newsletter.

I am currently the NP SIG Web stie administrator and am responsible for periodically updating the Web page information. If you have any questions or concerns, or would like to see specific information on the Web page, please feel free to contact me at bcahill@nmff.org.

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Special Interest Group Newsletter  March 2004

If the Majority Leads, the Leaders Will Follow

Wendy H. Vogel, MSN, FNP, AOCN®
Kingsport, TN

I recently was honored by being asked to represent ONS at the American Academy of Nurse Practitioners (AANP) Health Policy Leadership Fellowship. I learned some very interesting things at this meeting; probably the most interesting was that there are two things you don’t want to see made: sausage and law!

In some ways, it seemed that the process of politics was quite disheartening. It often is a game, and the one who shouts the loudest and has the most to offer usually wins. So why would any oncology nurse practitioner (NP) want to spend his or her time trying to influence health policies?

I think that the answer to that is the same as the reasons we went into nursing: We care about people and their health. As nurses, we view patients in a holistic sense. In today’s world, the holistic view also must include influencing health policies that affect each of us. We have to start at this level to make significant health changes in America.

But while we are advocating for patients, we often forget ourselves, don’t we? Nursing traditionally has been a women’s profession. And while we are busy nurturing the world, we have let our profession become downtrodden. If we don’t speak up for our profession, who will?

The first thing we learned at this meeting was how a bill becomes a law. The process can be overwhelming, and the rules can change! If you aren’t familiar with the process, I encourage you to look at some of the suggested readings given at the end of this article.

At the meeting, we learned about the issues that presently were affecting NPs. We listened to speakers from various areas of the legislative process and were able to ask questions and discuss these issues with them. Here are a few of the issues.

  1. Managed Care Issues
    • NPs need to be recognized as primary care providers (PCPs) on managed care provider panels so that patients may have access to them as providers and that NPs may order services that only PCPs may authorize. Any legislation that is written must have nondiscriminatory language (i.e., define PCP, not just say physician).
    • PCPs need to determine medical necessity for patients, not managed care administrators. NPs should have the right to determine what is medically necessary for their patients.
    • NPs need to be able to request reviews of denied claims on the behalf of patients rather than finding a physician to make the claim on their behalf.
  2. Medicaid Issues
    • Legislation needs to facilitate the use and reimbursement of NPs as PCPs in state Medicaid programs. The problem is that to provide more cost-effective Medicaid services, states have been given permission to request waivers that preempt federal regulation to develop innovative state-driven Medicaid managed care programs. These programs have, in some states, created new barriers for NPs to practice as PCPs by excluding them as PCPs.
  3. Long-Term Care
    • A change is needed in the Medicare Conditions of Participation for NPs to be able to perform the initial or admitting examination of a patient in a skilled nursing facility or hospice. At this time, regulations that were written more than 10 years ago required that only physicians could perform this service. This has resulted in patients not receiving adequate and timely care in many cases.
  4. Medicare Reimbursement
    • AANP was hard at work in lobbying for legislation or reinterpretation of Medicare statutes that would authorize home health agencies and hospices to accept orders from NPs. The issue here, again, was the need to have a language change or expanded interpretation of the word “physician.”
  5. Other issues: tobacco control, increasing nurse education funding (which we won!), and the nurse staffing act.
Why is it important for you to be a part of this? How can you have the time? What can you, as an individual, do? I have asked myself all these questions too. We must all stand up and have a voice. Nursing is a strong body, yet traditionally, we have been silent. We could be very powerful. We are loved and we are scarce!! But, if we don’t stand up for ourselves, our profession, and our patients, who will? If we stand as a majority, our leaders will follow our cues. So, what can you do?
  1. Support our lobbyists at a national and a state level. Make regular contributions to our political action committee organizations.
  2. Stay updated! Join the list serves for ONS, AANP, and American Nurses Association (ANA) legislative issues. Keep yourself informed on the latest issues.
  3. Know your legislators at national, state, and local levels. Go to legislative community meetings. Let them know that you are an NP and you are their constituent. Remember that they are employed by us.
  4. Tell your stories. Invite patients to tell their stories. Give legislators photo opportunities. Give them fact sheets on where you stand on the issues. You can get this information from the ONS, AANP, and ANA Web sites. Legislators are more likely to listen to you because you are out there working, not a “hired gun.” You don’t have to be an expert in the legislature—you are the expert in your field. Take every opportunity to educate anyone who will listen about what a NP is and what you do.
  5. Write letters and e-mails and make phone calls. Use ONS’s form e-mails, which you can personalize and send right from ONS’s Web site. Now, how easy is that? Have your patients, family, friends, and physician friends do the same. Visit your legislators when you are in Washington or your state capitol. Legislators use the “cockroach theory”: where there is one, there are probably hundreds more behind the wall. So every contact you make with your legislators counts!
We may have many excuses and even legitimate reasons that we are not individually more politically active. But if we are to survive as a profession, we must sit up and pay attention. We must get involved individually. I challenge each of you, in the new year of 2004, to stand up and make noise! Be the squeaky wheels! Get up and lead so our leaders will follow.

Suggested Readings
American Nurses Association. (2004). Government affairs. Retrieved February 10, 2004, from http://www.ana.org/gova

Oncology Nursing Society. (2004). Top 10 tips for a successful Capitol Hill advocacy visit. Retrieved February 10, 2004, from http://www.ons.org/LAC/Top_Ten.pdf

Oncology Nursing Society. (2004). Top 10 tips for written or oral advocacy communications with policymakers. Retrieved February 10, 2004, from http://www.ons.org/LAC/TopTenWriting.pdf

Towers, J. (2004). When did you last talk with your legislator? Austin, TX: American Academy of Nurse Practitioners. Retrieved February 10, 2004, from http://www.aanp.org

U.S. Department of Health and Human Services. (2004). Department of Health and Human Services organizational chart. Retrieved February 10, 2004, from http://www.hhs.gov/about/orgchart.html

U.S. Office of Citizen Services and Communications. (2004). Contact your government. Retrieved February 10, 2004, from http://www.firstgov.gov/Contact.shtml

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Special Interest Group Newsletter  March 2004

Native Americans Experience Barriers to Cancer Care

Emily Haozous, RN, MSN
New Haven, CT

Very little published research addresses the Native American population with cancer. This article will briefly describe some of the barriers and cultural context that affect cancer care and prevention for Native Americans. Understanding this relatively small population of patients requires knowledge of the context in which they live. Typically, Native Americans living on reservations have poor access to healthcare systems compounded by severe poverty, alcoholism, and little access to social services. The Indian Health Service (IHS) has clinics and provides medical services for most reservation Native Americans, but their care does not cover onsite oncology services. Any Native American requiring oncology care must leave the reservation clinic and their traditional community to seek care in larger urban settings (Burhansstipanov & Hollow, 2001). In addition, IHS policy grants health care only to Native Americans who are able to prove membership in federally recognized tribes. More than 100 of the 500-plus Native American tribes in the United States still are unrecognized by the federal government, making the members of those tribes ineligible for services from IHS (Petersen et al., 2002).

Limitations in access to federally supported IHS clinics for all Native Americans results in later stage diagnoses and delays in treatment. For example, Native American women with cancer are four times more likely to receive their first cancer-directed surgery more than six months following diagnosis (Burhansstipanov & Hollow, 2001). Very few Native Americans have private health insurance to cover costs, so they must rely on funding from the IHS. The rural nature of most reservations, combined with poor access to resources and distance from cancer centers, results in a proportionally higher mortality rate from cancers for Native Americans nationwide (Burhansstipanov & Hollow). For the cancer incidence and mortality statistics from 1992–1999, the average incidence for cancer in Native Americans was 244.6 people per 100,000 and mortality was 128.6 people per 100,000, or 57% mortality. In contrast, the incidence for Caucasians was 480.4 per 100,000 and mortality was 205.1 per 100,000, or 43% (Jemal et al., 2004). In addition, few Native American healthcare providers are available to act as bridges between the world of western medicine and the Native American culture.

In addition to systemic barriers, many Native American tribal cultures have cultural barriers that prevent Native Americans from participating in cancer screening activities. For example, the Pap test violates the Yakama belief that all cells are important to the human body and should not be removed. Screening activities in this community had to be modified to accommodate this important cultural belief (Strickland, Squeoch, & Chrisman, 1999). Among the people of the Navajo nation, discussion of cancer is taboo. Traditional Navajos believe that thought and language have the power to influence reality. Therefore, talk about cancer, or any health issue, will have the power to bring that disease into being. The practitioner managing care in this population must pay special attention to the manner in which they address patients and the healthcare issues at hand. Discussion requires attention to avoid referring to patients as having cancer or to the disease state, because that will imply that care providers wish that disease on the people they are addressing (Carrese & Rhodes, 1995). Although best documented in the Navajo nation, many tribal communities in the United States share this health belief.

Research by the author has indicated that social isolation is a prominent aspect of cancer and the cancer pain experience in Native Americans (Haozous, 2004). Because of the cultural taboo of discussing cancer and cancer pain, combined with the desire to appear healthy and strong, individuals with cancer withdraw from participation in community activities while experiencing symptoms from cancer and cancer treatment. As a result, cancer sufferers on the reservation experience acute isolation. The community-based cancer support group concept still is new to Native American communities and, although some support groups exist in more densely populated areas, geographic limitations force many Native Americans with cancer to endure the experience in relative isolation.

Cancer care has multiple barriers for Native Americans. Institutional barriers result in delays in diagnosis and treatment, as well as isolation from traditional communities during care and possible refusal of treatment based on policy issues. Cultural barriers exist in beliefs about screening activities as well as about cancer and cancer cause. The cancer experience itself is isolating, making the process of diagnosis and treatment even more unattractive. Current research is focused on identifying strategies to make screening activities more culturally congruent to decrease morbidity and mortality in Native American communities.

Burhansstipanov, L., & Hollow, W. (2001). Native American cultural aspects of oncology nursing care. Seminars in Oncology Nursing, 17(3), 206–219.

Carrese, J.A., & Rhodes, L.A. (1995). Western bioethics on the Navajo reservation: Benefit or harm? JAMA, 274, 826–829.

Haozous, E.A. (2004). Understanding the cancer pain experience in the Plains Native American population. New Haven, CT: Yale University.

Jemal, A., Murray, T., Samuels, A., Ghafoor, A., Ward, E., & Thun, M.J. (2004). Cancer statistics, 2004. CA: A Cancer Journal for Clinicians, 53, 5–26.

Petersen, W.O., Trapp, M.A., Vierkant, R.A., Sellers, T.A., Kottke, T.E., de Groen, P.C., et al. (2002). Outcomes of training nurses to conduct breast and cervical cancer screening of Native American women. Holistic Nursing Practice, 16(2), 58–79.

Strickland, C.J., Squeoch, M.D., & Chrisman, N.J. (1999). Health promotion in cervical cancer prevention among the Yakama Indian women of the Wa’Shat Longhouse. Journal of Transcultural Nursing, 10, 190–196.

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Special Interest Group Newsletter  March 2004

Drug Update
New Antiemetic Treats Chemotherapy-Induced Nausea and Vomiting

Christie M. Hancock, APN, MSN, RN, CS, OCN®
Jonesboro, AR

Nausea and vomiting are two of the most common symptoms associated with chemotherapy. A 1993 report of survey findings documented that patients ranked the feelings of “being sick” (vomiting) and “feeling sick” (nausea) as the two most feared treatment-related effects of cancer chemotherapy (Coates et al., 1993). The incidence of nausea and vomiting depends on the chemotherapeutic regimen and combination of agents prescribed. Chemotherapeutic agents can be classified as low, moderate, and high regarding their emetogenic potential. Examples of highly emetogenic chemotherapeutic agents include cisplatin, cyclophosphamide, doxorubicin, and methotrexate (Goodman, 1997). If a patient is to receive a combination of several highly emetogenic agents (i.e., cyclophosphamide and doxorubicin for treatment of breast cancer), his or her risk for experiencing nausea and vomiting is increased significantly.

Chemotherapy-induced nausea and vomiting can be characterized as acute, delayed, persistent, and anticipatory. Cisplatin and other moderately to highly emetogenic chemotherapy can induce nausea and vomiting that persists for several days in almost all patients who do not receive adequate antiemetics, and delayed or persistent nausea and vomiting also may occur after administration of agents considered to be mildly to moderately emetogenic (Wickham, 1999). Chemotherapy-induced nausea and vomiting can severely impact a patient’s quality of life as well as activities of daily living. As healthcare practitioners, these symptoms must be recognized and treated adequately.

In March 2004, the U.S. Food and Drug Administration (FDA) approved Emend® (aprepitant, Merck & Co., Inc., Whitehouse Station, NJ) for the treatment of chemotherapy-induced nausea and vomiting. Emend, in combination with other antiemetic agents, is indicated for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy, including high-dose cisplatin (Merck & Co., Inc., 2004). Emend’s primary ingredient, aprepitant, is a selective high-affinity antagonist of human substance P/neurokinin1 receptors. It has little or no affinity for serotonin (5-HT3), dopamine, or corticosteroid receptors.

Clinical Trials
FDA approval of Emend was based on two multicenter, randomized parallel, double-blind, controlled clinical studies. Treatment with aprepitant was compared with standard therapy in subjects receiving a chemotherapy regimen that included cisplatin > 50 mg/m². Results showed that Emend, in combination with ondansteron (Zofran®, GlaxoSmithKline, Research Triangle Park, NC) and dexamethasone (Decadron®, Merck & Co., Inc.), prevented acute and delayed nausea and vomiting associated with highly emetogenic chemotherapy, including high-dose cisplatin (Merck & Co., Inc., 2004).

More than 1,000 subjects were randomized to either the aprepitant regimen or standard therapy, with 95% of the subjects in the aprepitant group receiving a concomitant chemotherapeutic agent in addition to protocol-mandated cisplatin. The most common chemotherapeutic agents were etoposide, fluorouracil, gemcitabine, vinorelbine, paclitaxel, and doxorubicin. The aprepitant-treated subjects ranged in age from 14–84, with a mean age of 56 years (Campos et al., 2001; Navari et al., 1999).

In both studies, patients receiving the aprepitant had a complete response to antiemetic therapy in comparison to patients receiving standard therapy. An additional benefit is that the estimated time to first emesis after initiation of cisplatin treatment was longer with the Emend treatment, and the incidence of first emesis was reduced in the aprepitant regimen group compared with standard therapy (Merck & Co., Inc., 2004).

Dosage and Administration
The recommended dosage of Emend is 125 mg orally one hour prior to chemotherapy treatment (day 1) and 80 mg once daily in the morning on days 2 and 3. Emend is given as part of a regimen that includes a corticosteroid and a 5-HT3 antagonist. Emend is supplied in 80 or 125 mg capsules in bottles of 30. Merck & Co., Inc., also offers a “unit-of-use” trifold pack that contains one 125 mg capsule and two 80 mg capsules.

Emend should be used in caution with patients receiving concomitant medicinal products, including chemotherapy agents that are metabolized primarily through CYP3A4. Inhibition of CYP3A4 by aprepitant could result in elevated plasma concentrations of these concomitant medicinal products. The effect of Emend on the pharmacokinetics of orally administered CYP3A4 substrates is expected to be greater than the effect of Emend on the pharmacokinetics of IV administered CYP3A4 substrates.

Chemotherapy agents that are known to be metabolized by CYP3A4 include docetaxel, paclitaxel, etoposide, irinotecan, ifosfamide, imatinib, vinorelbine, vinblastine, and vincristine. In clinical studies, Emend was administered commonly with etoposide, vinorelbine, or paclitaxel. The doses of these agents were not adjusted to account for potential drug interactions (Merck & Co., Inc., 2004).

Patients taking the following medications may not take Emend because of its ability to inhibit CYP34A: pimozide, terfanadine, astemizide, and cisapride.

Side-Effect Profile
The most frequently reported adverse effects in the therapeutic trials of Emend were fatigue (17.8%), hiccups (10.8%), diarrhea (10.3%), dizziness (6.6%), dehydration (5.9%), abdominal pain (4.6%), and fever (2.9%).

In conclusion, Emend is the first of a new class of antiemetics that has been proven effective in the treatment of chemotherapy-induced nausea and vomiting. It is always used concomitantly with a regimen of other medications (e.g., corticosteroids and a 5-HT3 receptor agonist).

Campos, D., Pereira, J.R., Reinhardt, R.R., Carracedo, C., Poli, S., Vogel, C., et al. (2001). Prevention of cisplatin-induced emesis by the oral neurokinin-1 antagonist, MK-869, in combination with granisetron and dexamethasone or with dexamethasone alone. Journal of Clinical Oncology, 19, 1759–1767.

Coates, A., Abraham, S., Kye, S.B., Sowerbutts, T., Frewin, C., Fox, R.M., et al. (1993). On the receiving end: Patient perception of the side effects of cancer chemotherapy. European Journal of Cancer and Clinical Oncology, 29, 203–208.

Goodman, M. (1997). Risk factors and antiemetic management of chemotherapy-induced nausea and vomiting. Oncology Nursing Forum, 24(Suppl. 7), 20-32.

Merck & Co., Inc. (2004). Emend (aprepitant) product information. Whitehouse Station, NJ: Author.

Navari, R.M., Reinhardt, R.R., Gralla, R.J., Kris, M.G., Hesketh, P.J., Khojasteh, A., et al. (1999). Reduction of cisplatin-induced emesis by a selective neurokinin-1 receptor antagonist. New England Journal of Medicine, 340, 190–195.

Wickham, R.W. (1999). Nausea and vomiting. In C.H. Yarbro, M.H. Frogge, & M. Goodman (Eds.), Cancer symptom management (2nd ed., pp. 228–253). Sudbury, MA: Jones and Bartlett.

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Special Interest Group Newsletter  March 2004

Nurse Practitioner SIG Officers

Diane Cope, PhD, ARNP-BC, AOCN®
605 Astarias Circle
Fort Myers, FL 33919-3247
941-437-3571 (H)
941-437-4444 (O)

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

Janet VanCleave, MSN, ACNP-CS, AOCN®
11 E. 87th St., Apt. 8A
New York, NY 10128
212-289-7849 (H)
212-241-7921 (O)


Christie Hancock, APN, MSN, RN, CS, OCN®
225 East Jackson
Jonesboro, AR 72401
870-935-4546 (H)
870-972-4510 (O)

ONS Publishing Division Staff

Elisa Becze, BA
Copy Editor


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

Diedrea White, Manager of Member Relations and Diversity Initiatives

Carol DeMarco, Membership/Leadership Administrative Assistant

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Oncology Nursing Society
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Pittsburgh, PA 15275-1214
ONS Online: www.ons.org

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