Volume 23, Issue 1, May 2012
Coordinator's Message

Margaret (Peg) Rosenzweig, PhD, FNP-BC, AOCNP®
Associate Professor
University of Pittsburgh
Pittsburgh, Pennsylvania

Many years ago, one of my professors in my Master's Family Nurse Practitioner program told us laughingly, "The responsibility of the nurse practitioner is always in direct proportion to the number of people in the waiting room." At the time, I did not appreciate the wisdom of that comment but I think it is more true today then it was all those years ago.

The 2010 Health Care Affordability Act allows access to care for many Americans previously uninsured due to cost or preexisting conditions. If the predictions for increased patient access are true, there will be "more people in the waiting room." This influx of patients will increase the need for healthcare providers, specifically nurse practitioners. There is great potential impact on nurse practitioners overall and specifically cancer care nurse practitioners.

Federal money is becoming available for NPs in independent practice or in the context of the "medical home," a coordination of care providers to decrease redundancy and increase efficiency within the healthcare delivery system. Although the concept is traditionally designed for the primary care provider, this can be applied to cancer care. As the community oncology practice is asked to provide more navigation, counseling, disease accounting, adherence to guidelines and patient assistance with financial matters (Sprandio, 2010), the role for the nurse practitioner in cancer care coordination is obvious.

Some models of the "medical home" have the NP as the primary coordinator of care. This role in cancer care is unwritten but could easily be developed. We need to be creative in thinking about ways to capture these opportunities. We don't know yet what the medical home may look like or what impact it will have on cancer care but as nurse practitioners, we need to be aware of these upcoming initiatives. We all need to be aware of trends and to keep in touch with our legislative officials on the local, state, and federal level in order to help shape policy initiatives that will relate to our practice. The future is really exciting for nurse practitioners. We don't have to accept a healthcare system that is poorly coordinated, fragmented, and not patient focused. We can help to create a patient-centered, coordinated, evidence-based, and outcome-focused cancer care delivery system. All of those people in the waiting room are counting on us.

Sprandio, J. (2010). Oncology patient-centered medical home and accountable cancer care. Community Oncology, 7, 565572. doi:10.1016S1548-5315(11)70537-X

The Nurse Practitioner SIG Newsletter is produced by members of the
Nurse Practitioner SIG and ONS staff and is not a peer-reviewed publication.

Special Interest Group Newsletter  May 2012

The "History of the Present Illness":
Considerations for the Nurse Practitioner in Medical Oncology
Margaret (Peg) Rosenzweig, PhD, FNP-BC, AOCNP®
Associate Professor
University of Pittsburgh
Pittsburgh, Pennsylvania

The critical piece of the patient history that helps to clarify the patient "story" as it relates to their presenting complaint is the History of the Present Illness (HPI). We learn that the HPI is an opportunity to learn about the characteristics of the presenting sign or symptom. We ask about onset, location, duration, characteristics, aggravating, relieving factors, and the temporality of the presenting sign or symptom.

The HPI in medical oncology for the traditional "new" patient is different in that the diagnosis is usually well established. In cancer care we need to establish the "story" of the cancer diagnosis, the diagnostic work-up to date, any relevant social, family, past medical history that has an impact on the cancer diagnosis and potential treatment. Additionally the HPI in cancer allows an important opportunity for the patient to retell a story that is emotionally difficult, starting to put the emotional trauma of cancer diagnosis into some perspective.

With an empathetic listener, the retelling of a medical trauma can itself be therapeutic (Adler, 1997). It also provides the nurse practitioner obtaining the history an opportunity to establish a bond with a new patient and family, to assess the patient's emotional response to the cancer diagnostic process, the patient's experience and competence in dealing with the healthcare system, their level of resilience and potential for distress during further cancer therapy.

The components of the HPI in cancer care should begin with "the patient was in their usual state of health when," thus beginning the story of the cancer diagnosis, or what is known to date. Usually a patient will tell a story of noting an abnormality in a sign or symptom that may have been self-treated or disregarded as not serious for some time. Ultimately, this sign or symptom will have been presented to a medical professional. Delays in obtaining routine screening or in seeking evaluation for a sign or symptom that results in a cancer diagnosis, for whatever reason, can result in patient guilt as if they "brought this on themselves." If an NP is detecting self-blame an empathetic response may be a statement acknowledging these feelings but concentrating on doing what is best moving forward.

Of course, it is unusual for patients presenting with signs or symptoms of cancer to first see a cancer care provider. Usually patients first present to primary care physicians or a host of specialists who will analyze the signs and symptoms and begin the diagnostic work-up, with cancer in the differential diagnosis. These providers will order radiology, lab work, and or biopsy that results in a cancer diagnosis. Depending on the tumor type, the patient may then go to radiation, surgery or come directly to medical oncology. Regardless of the specific previous providers, it is important to capture the providers and the timeline in the HPI for the patient with cancer. The oncology NP can garner the emotional impact on the patient from this period of uncertainly. Once the timeline is established, the oncology NP can then gently ascertain if the patient and family know why they were referred to medical oncology and the patient's thoughts about the likelihood that he or she will receive systemic therapy.

After the diagnostic timeline is established, the NP needs to assemble the supporting information and documentation to ensure that the medical oncology decision is based on state-of-the-art information about the tumor. Each tumor type will have specific criteria for what is needed in order for treatment decisions to be made. The characteristics of the tumor include not just size, but grade and any genomic information relevant to clinical decision making. The proteomic information that is used for treatment decisions continues to evolve, challenging NPs to understand the continually expanded knowledge regarding carcinogenesis and pathways of cellular activation used for therapeutic targets. Measurement issues are also controversial, and the NP should be aware of "gold standard" measurement for commonly used proteomic information. Lymph node status, extent of metastatic work-up, any laboratory work-up including appropriate tumor markers and any testing performed in preparation for chemotherapy (MUGA, PFT) must also be included.

Once the story is established, the rest of the history is then completed as per traditional history taking with an eye toward any important information being moved to the HPI. The consideration to move components of the patients history to the HPI for a newly diagnosed patient with cancer is the impact that this information would have on prognosis or the ability of the patient to receive chemotherapy without great physical or emotional distress. Components of the past medical history, social history, family history, or review of systems may or may not be very relevant to the presenting cancer and the ability to appropriately treat this cancer with systemic therapy.

The creation of the HPI in cancer care is a unique opportunity to gather all of the relevant information regarding the cancer diagnosis in order for the treatment decision to be made with the best information. Importantly, the HPI allows the NP to place that information in the context of the patient's story and begin to assist the patient and family with the creation of an illness narrative (Donnelly, 1988). The process of eliciting this story with the patient and family can help to establish an important bond between the NP and patient.

Adler, H.M. (1997). The history of the present illness as treatment: Who's listening, and why does it matter? Journal of the American Board Family Practice, 10, 28-35.

Donnelly, W.J. (1988). Righting the medical record. Transforming chronicle into story. JAMA 260, 823825. doi:10.1001/jama.1988.03410060093034

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Special Interest Group Newsletter  May 2012

ONS Quality Initiative Takes Shape
Kristen Fessele, RN, MSN, ANP-BC, AOCN®
ONS Research Associate
Pittsburgh, PA

An exciting meeting took place at the ONS offices in Pittsburgh on June 24-25, where national experts from nursing, medical, and specialty organizations with a focus on quality joined ONS members and staff to share best practices, current opportunities, and challenges. The "Taking Stock of Quality" meeting allowed project team members to consider a broad perspective of the quality landscape as they formulated a multi-year plan of potential activities to support the new Quality Pillar of the ONS Strategic Plan.

The 2012-2015 Quality Pillar's description holds that ONS will support the development, dissemination, and evaluation of patient-centered interventions and their contributions to high-quality cancer care. To meet this goal, we hope to collaborate with other organizations that are active in the national quality environment and to develop a culture of quality in daily practice among nurses caring for patients with cancer or who are at risk for cancer. A cross-cutting theme throughout each aspect of the Pillar objectives relates to the need to help ONS members learn about and embrace the links between individual research findings, evidence syntheses such as ONS Putting Evidence Into Practice (PEP) and other resources, and high-quality cancer care.

In related news, testing of the Breast Cancer Survivorship (BCS) quality measure set, the second set developed and in testing in collaboration with The Joint Commission, is under way at approximately 40 clinical practice sites across the nation. As with the Breast Cancer Care (BCC) measure set tested in 2010, pilot sites were selected to represent a variety of "real world" practice types in terms of size, geography, academic status, ownership type, and level of urbanization. The BCS quality measures focus on patient care from the time therapy is completed early stage breast cancer through the first 12 months of post-treatment survivorship, and essentially pick up where the BCC set leaves off. The measures look for continued assessment (and in the case of fatigue and distress, hopeful improvement over the immediate post-treatment baseline levels) of symptoms, education, follow-up/coordination of care, and patient-centered goal setting. To learn more about these quality measure sets, visit the ONS Quality Initiative page on the ONS website or email research@ons.org. Between the quality measure work under way and the creation of the new Quality Pillar in the ONS Strategic plan to take us beyond the current projects, exciting activities are happening!

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Special Interest Group Newsletter  May 2012

Drug Update on Bevacizumab
Tamika Turner, MS, NP-C, AOCNP®
IU Health Cancer Center
Indianapolis, Indiana

Bevacizumab (Avastin®) was approved in 2008 for metastatic breast cancer. Avastin is a monoclonal antibody that binds to the VEGF protein preventing it from angiogenesis (promoting new blood vessel growth).

It gained approval through the U.S. Food and Drug Administration's (FDA's) Accelerated Program. Genentech, the sponsor of Avastin, completed two additional clinical trials and submitted that data to the FDA. These data showed a small effect on tumor growth with no evidence that patients lived longer or had a better quality of life compared to those taking standard chemotherapy alone. Avastin has potentially life-threatening risks, including severe high blood pressure; heart attack; heart failure; bleeding; hemorrhaging; and the development of perforations in different parts of the body such as the stomach, intestines, or nose.

The FDA felt the indication for metastatic breast cancer should be removed from Avastin's label because of these potentially life-threatening side effects, no data to support slowing tumor growth, no data to support women living longer, or women having a better quality of life.

The FDA made the decision to revoke Avastin's indication for metastatic breast cancer on November 18, 2011 and recommends that patients currently receiving Avastin as part of their treatment speak with their oncologist regarding alternative treatment options. Avastin will continue to have its indications for lung, colon, kidney, and brain cancers.

Currently, three lines of standard chemotherapy agents are approved for metastatic breast cancer. First-line therapies include paclitaxel plus gemcitabine or paclitaxel plus trastuzumab. Second- and third-line therapies include: paclitaxel; docetaxel; capecitabine; trastuzumab; lapatinib; ixabepilone; eribulin mesylate; and capecitabine plus docetaxel or capecitabine plus docetaxel.

Advanced practice nurses spend quite a bit of time educating patients. It is your duty to familiarize yourselves with this updated information and help your patients understand. Explain that Avastin's approval has been pulled for the safety of patients and other chemotherapy agents are available and approved for treatment of metastatic breast cancer.

Genentech, Inc. (n.d.). Avastin® [Product information]. Retrieved from http://www.gene.com/gene/products/information/oncology/avastin/

Riley, K. (2011, November 18). FDA commissioner announces Avastin decision [Press release]. Retrieved from http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm280536.htm

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Special Interest Group Newsletter  May 2012

Exciting New Training Opportunity for Nurse Practitioners Interested in Research:
Pre-Doctoral and Post-Doctoral Fellows in Cancer Survivorship Research
Catherine Bender, PhD, RN
University of Pittsburgh School of Nursing
Pittsburgh, PA 15261

The oncology faculty from the University of Pittsburgh School of Nursing are pleased to announce the availability of an Interdisciplinary Training Program for Nurse Scientists in Cancer Survivorship Research (T32 NRO11972) funded by the National Institute of Nursing Research. The purpose of the T32 Institutional Research Training Grants is "to provide pre-doctoral and post-doctoral research training opportunities for individuals interested in pursuing research careers in biomedical, behavioral, and clinical research."

The goal of the T-32 at the University of Pittsburgh is to prepare nurse scientists to lead independent programs of theory-based research in cancer survivorship. This is the only training effort of its kind specifically devoted to oncology nursing in the United States. This award will support the training of both pre-doctoral and post-doctoral fellows providing tuition, an annual stipend and research support. Pre-doctoral trainees can be enrolled in either our BSN to PhD program or the MSN to PhD Program.

Each trainee will participate in a rigorous training program in which they will work with oncology nurse scientists with outstanding records of conducting critical, multidisciplinary studies in cancer survivorship. The oncology faculty includes Drs. Catherine Bender, Susan Cohen, Heidi Donovan, Margaret Rosenzweig, and Paula Sherwood. Trainees will also have the opportunity to work with training faculty from multiple disciplines from across the schools of the University of Pittsburgh and Carnegie Mellon University and from the University of Pittsburgh Cancer Institute, a National Cancer Institute-designated Comprehensive Cancer Center. In addition, trainees will complete individualized academic curricula composed of coursework, seminars, journal clubs, and a visiting scholar series focused on the trainee's goals and research focus.

For specific information about the training program and the application process please contact Catherine Bender, PhD, RN, FAAN, program director at cbe100@pitt.edu or 412-624-3594 or visit the Cancer Survivorship T32 website.

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Special Interest Group Newsletter  May 2012


RE:Connect is a blog written by oncology nurses on a variety of topics of interest to other nurses in the specialty, including facing day-to-day challenges at work, juggling busy lives at home, and keeping up to date with the magnitude of information available for practicing nurses. This month on RE:Connect, you'll find the following new discussions.

As a reader, join in on the conversation and connect with other oncology nurse readers by posting your own stories, tips, ideas, and suggestions in the comments section at the end of each blog post.

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Special Interest Group Newsletter  May 2012

Five-Minute In-Service

In the latest issue of ONS Connect, the Five-Minute In-Service takes a look at Nursing Considerations for Patients Receiving Pazopanib for Renal Cell Carcinoma.

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Special Interest Group Newsletter  May 2012

Do You Enjoy Writing?
Become an ONS Blogger

Join Patients and Caregivers on the Cancer Journey!
We're looking for oncology nurses to write for Traveling Companions, ONS's patient- and caregiver-focused blog. If you'd like to share your thoughts and comments to support patients and caregivers on the cancer journey, please e-mail us at socialmedia@ons.org for consideration.

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Special Interest Group Newsletter  May 2012

ONS Podcasts of Interest

ONF Podcasts
When does nausea and vomiting usually occur in children receiving chemotherapy? What strategies do they use to cope? How effective are these strategies?

In this month's podcast, lead author Cheryl Rodgers, PhD, RN, CPNP, CPON®, addresses these questions and presents implications for oncology nurses as she discusses her March 2012 ONF article "Children's Coping Strategies for Chemotherapy-Induced Nausea and Vomiting." Previous research investigating the frequency and duration of chemotherapy-induced nausea and vomiting (CINV) in pediatric patients with cancer has been limited. This descriptive study not only evaluates frequency, duration, and distress of CINV but also expands upon previous research. With a greater understanding of this chemotherapy symptom experience, effective management strategies can be developed for this patient population.

CJONPlus Podcasts
A new diagnosis of lung cancer is a highly threatening experience that raises personally relevant existential issues and brings death-related thoughts and concerns to mind. Those issues can be very disturbing to patients, leading to distress and potentially to a lowered quality of life.

This month's CJONPlus podcast features an interview with Rebecca H. Lehto, PhD, RN, OCN®, author of the February 2012 CJON article "The Challenge of Existential Issues in Acute Care: Nursing Considerations for the Patient With a New Diagnosis of Lung Cancer." During the interview, Dr. Lehto expands on her article and discusses her inspiration for sharing the existential and death concerns of patients with lung cancer as well as practical strategies and resources available to nurses caring for these patients.

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Special Interest Group Newsletter  May 2012

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Special Interest Group Newsletter  May 2012

Nurse Practitioner SIG Officers

Coordinator (20102012)
Margaret (Peg) Rosenzweig, PhD, FNP-BC, AOCNP®
Sewickley, PA

Coordinator-Elect (2011-2012)
Tamika Turner, MS, NP-C, AOCNP®
Indianapolis, IN

Margaret (Peg) Rosenzweig, PhD, FNP-BC, AOCNP®
Sewickley, PA

Web Page Administrator
Open Position


Legislative Issues
Wendy H. Vogel, RN, MSN, FNP, AOCNP®
Bristol, TN

Barbara Biedrzycki, RN, MSN, CRNP, AOCNP®

ONS Copy Editor
Laura J. Pinchot, BA
Pittsburgh, PA

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