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Please read this article and comment below/answer the questions in order to receive 0.5 CE.
Have you cared for a patient experiencing any of these oncologic emergencies?  If so, which one and what were their symptoms?
Do you think you would be able to recognize if any of your patients are experiencing an oncology emergency?

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February/March 2021 Journal club article

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February/March 2021 Journal club article

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This article also talks about the effects of Covid on cancer patients. I'm sure you have seen a lot of the effects of Covid discussed in this article on your patients. What are your thoughts on telehealth? How has telehealth gone so far with your patients? Do we need to get creative & innovative with cancer care in order to protect patients throughout this pandemic? Do you have any creative or innovative ideas? Have cancer patients suffered because of the pandemic?

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Many physicians are now at the front lines of the COVID-19 pandemic. Those who do not have direct COVID-19 roles, including those in cardio-oncology, are trying to maintain normality in medicine as much as possible amid the chaos.

We continue educating medical students and trainees, performing and writing research papers and articles, and taking care of patients. But the system is much different from what we are used to.

We now have telehealth.

According to the American Academy of Family Physicians, telehealth is the practice of medicine using technology to deliver care at a distance. This means that a physician in one location could use a telecommunications infrastructure like a mobile phone or computer to deliver care to a patient at a distant site.

Telehealth in COVID era

In the United States, telehealth was initially reserved for patient care in rural areas with limited in-person physician availability. However, with the COVID-19 outbreak and to facilitate the social distancing recommendations, Medicare began to cover routine office visits via telehealth. Most hospitals have therefore switched outpatient care to telehealth. Furthermore, in the context of the COVID pandemic, telehealth has been promoted by major public health organizations such as WHO and CDC as the standard of care in place of routine office visits.

Telehealth in the era of COVID presents an example of the complexity of risk-benefit decision-making that we make every day. We have to decide which patients to see urgently amid the contagion risk and which can be deferred. Similarly, we need to decide which tests can wait and for how long. This is a particularly acute dilemma for patients with cancer and heart disease.

High-risk population

About 1.8 million people will be diagnosed with cancer in the U.S. in 2020, 5% of whom have elevated risk for heart disease, according to estimates from the American Cancer Society. Unfortunately, this same population - our clinic patients with heart disease and cancer - are also at highest risk for infection, complications and death from COVID-19 due to their cancer, heart disease or a combination of both.

Recent data from China indicate that patients with COVID-19 and a history of cancer were nearly five times more likely to develop severe disease as defined by ICU level of care or death (39% vs. 8%) compared with those without cancer history. Furthermore, 75% of those who had received chemotherapy recently developed severe infection compared with 43% among those without recent chemotherapy.

Telehealth concerns

The safety from COVID-19 of our immunocompromised patients is paramount and the decision to reduce in-person clinic visits is undoubtedly appropriate for the circumstances, there are some concerns regarding possible disruptions and complications that could result from the practice of telehealth in our cardio-oncology patients.

Foremost is the concern for delayed treatment. For our patients with cancer, individualized decisions are being made to postpone nonurgent chemotherapy, elective surgeries and even some radiation therapies as a result of COVID-19. Similarly, from a heart disease standpoint, we have deferred some basic cardiac procedures such as ECGs, echocardiograms, stress tests and even simple blood draws (for cardiac biomarkers, renal function and electrolytes), which would usually inform us regarding each patient's cardiac condition to help tailor cardiac care during and after cancer treatment. These issues present a particular challenge for diagnosis and management of new high-risk patient referrals to cardio-oncology.

Downstream effects

As we try to balance patient care and make treatment and procedural interruptions for COVID-19, we should be concerned about possible non-COVID downstream negative effects, including morbidity and mortality caused by delays in diagnosis and treatment of these patients with heart disease and cancer. In the cardio-oncology population, timing is crucial in the identification and treatment of patients with potential cardiotoxicity.

There are also limitations on decision-making with telehealth. The best we can do with telehealth is to visualize a patient by video - which not all patients have the technological know-how to do, least of all our underserved/minority population. A telephone visit that most patients can afford is even less ideal since we can only rely on voice information.

Either way, we cannot touch, feel or accurately examine for signs of heart disease or HF. The resulting clinical decision-making process is therefore undeniably flawed, particularly in such a high-risk population of cardio-oncology patients.

Numerous changes

To combat some of these concerns as much as possible, we are asking our patients to measure and record their BP, heart rates, weights and oxygen saturations at home, and provide these numbers to us during the televisit.

Even then, some patients are still limited in their ability to provide these measurements due to lack of funds for the electronic gadgets, limitations in technological know-how, and/or lack of social support to help make this possible. Most of these limitations are especially true for our older patients who also happen to be our most vulnerable.

The changes to treatment and surveillance schedules are also a source of great anxiety to many patients. Open, compassionate and honest communications about these concerns are important in addressing difficult treatment decisions and potential delays in care.

Furthermore, we cannot comfort our patients in the same way. There is a distant dynamic in trying to build a new patient-physician relationship through a phone or video call.

And for the rest of our patients, we have asked them to postpone their visits - and therefore their health care - for the next 2 to 4 months until after the outbreak. This will create a backlog of patients for clinic visits, procedures, surgeries and treatments that will need to be addressed later when life is back to normal after COVID-19.

Winning the battle

Finally, there is the question of what could happen to those who develop significant oncologic problems such as disease progression and/or cardiac complications such as HF in the interim. Some will likely end up in the emergency room amid the COVID-19 excitement. They then run the risk of contracting the infection despite their practiced social distancing at home.

Others will deal with these complications of treatment delays later, after the COVID-19 hustle and bustle. By then, hopefully, it will not be too late to treat them because that would mean in some twisted way that COVID-19 had won, and the toll of COVID-19 would extend well beyond the number of people who tested positive. And after all this raging battle, we cannot let that happen. Not to our patients with cancer, whether they have heart disease or not.

References:

For more information:

Tochi M. Okwuosa, DO, is associate professor of medicine and cardiology and director of the Cardio-Oncology Program at Rush University Medical Center. She can be reached at tokwuosa@rush.edu.

Nausheen Akhter, MD, is assistant professor in the division of cardiology at Northwestern University Feinberg School of Medicine.

Jeanne DeCara, MD, is professor of medicine and director of the Cardio-Oncology Program at University of Chicago Medical Center.

Chris P. Gans, MD, is assistant professor of clinical medicine at director of the Onco-Cardiology Program at University of Illinois.

Javier Gomez-Valencia, MD, MS, is director of the Stress Laboratory, Nuclear Cardiology and Cardiac Station at Cook County/Stroger Hospital.

Haseeb Ilias Basha, MD, is assistant professor in the division of cardiovascular medicine at Loyola University.

Sunil Pauwaa, MD, is a cardiologist at University of Illinois.

Amit Pursnani, MD, is a cardiologist in the division of cardiology at Northshore University Health System.

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Telehealth in the era of COVID-19: Concerns for patients with cancer, heart disease

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Many physicians are now at the front lines of the COVID-19 pandemic. Those who do not have direct COVID-19 roles, including those in cardio-oncology, are trying to maintain normality in medicine as much as possible amid the chaos. We continue educating medical students and trainees, performing and writing research papers and articles, and taking care of patients.

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This article seems like it was written so long ago although it was only in April.  A lot of changes have occurred during this pandemic.  How do you think those changes will impact Cancer Care?  Do you think some of the changes will remain as our "new normal"?

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February journal article...can you relate?

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February journal article...can you relate?

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Read the article and comment below to receive 0.5 CE

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November journal article:  Please read & then add a comment below for discussion.  USP 800 is coming, do you know much about it?  Are we ready?

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November journal article:  Please read & then add a comment below for discussion.  USP 800 is coming, do you know much about it?  Are we ready?

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Police officers wear body armor and construction workers wear hard hats. Why? Because these professions carry inherent dangers in the line of duty-And oncology nursing does too.

Statistically, healthcare workers face more workplace-related dangers than both law enforcement and construction, yet attention to safety and personal protection isn't always a central focus. This can be especially true in cancer care, where nurses are required to administer hazardous drugs (HDs) and handle dangerous medications on a daily basis. Although safety recommendations exist, few enforceable standards are protecting nurses handling HDs.

Guidelines for safe handling have existed for years, yet dedicated safe-handling standards that were enforceable on a state level were still needed. According to ONS member Seth Eisenberg, RN, ADN, OCN ®, BMTCN ®, professional practice coordinator of infusion services at Seattle Cancer Care Alliance in Washington, USP's new chapter addresses the issue.

The road to implementation has been long for USP <800>. ONS member AnnMarie Walton, PhD, MPH, RN, OCN ®, CHES, assistant professor in the School of Nursing at Duke University in Durham, NC, has been actively following its trajectory since its inception.

The National Institute for Occupational Safety and Health's (NIOSH's) list of medications that currently meet the standards for hazardous drugs in practice is broken down into three groups:

Group 1: antineoplastic drugs, many of which may pose reproductive risks to susceptible populations

Group 2: non-antineoplastic drugs that meet NIOSH criteria for inclusion, many of which pose potential reproductive risks to susceptible populations.

Group 3: drugs that primarily pose reproductive risks to men and women actively trying to conceive, and women who are pregnant or breast feeding.

Find more information about NIOSH's hazardous drug list and view the current roster at the NIOSH website.

U.S. Food and Drug Administration's definition: A practice in which a licensed pharmacist, a licensed physician, or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist, combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.

: The practice of combining, admixing, diluting, pooling, reconstituting, repackaging, or otherwise altering a drug or bulk drug substance to create a sterile medication.

Written specifically for oncology nurses, ONS's Safe Handling of Hazardous Drugs (third edition) is a comprehensive overview of the latest details and procedures to keep yourself and your practice safe from potential hazardous exposures. Based on recommendations from the National Institute for Occupational Safety and Health, Occupational Safety and Health Administration, American Society of Health-System Pharmacists, and ONS, this essential guide helps providers navigate the complexities of hazardous drugs in practice.

For more information and sample chapters, visit ONS.org.

"The chapter has the greatest potential for affecting HD safety since the 2004 NIOSH alert," he says. "Although it's far from perfect-and is conspicuously pharmacy-centric in its content-they are the first required HD standards in the United States, and it will help ensure healthcare worker safety."

To discuss the information in this article with other oncology nurses, visit the ONS Communities.

To report a content error, inaccuracy, or typo, email pubONSVoice@ons.org.

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Handle With Care: How USP Will Affect Nursing Practice

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Police officers wear body armor and construction workers wear hard hats. Why? Because these professions carry inherent dangers in the line of duty­-And oncology nursing does too. Statistically, healthcare workers face more workplace-related dangers than both law enforcement and construction, yet attention to safety and personal protection isn't always a central focus.

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August/September article:                                 Have you ever used the Caritas room?

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August/September article:                                 Have you ever used the Caritas room?

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May/June article

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​PHILADELPHIA - Among melanoma patients treated with anti-PD-1 immunotherapy, consumption of a high-fiber diet was associated with higher gut microbiome diversity and better response to treatment, according to data presented during a media preview of the AACR Annual Meeting 2019, to be held March 29-April 3 in Atlanta.

"We found that diet and supplements appear to have an effect on a patient's ability to respond to cancer immunotherapy, most likely due to changes in their gut microbiome," said Christine Spencer, PhD, research scientist at the Parker Institute for Cancer Immunotherapy. "The gut microbiome plays a big role in moderating the immune system, so the idea that we could potentially change the microbiome-whether by diet or other means-to improve response to immunotherapy treatment is really exciting."

Spencer and colleagues from The University of Texas MD Anderson Cancer Center previously reported that melanoma patients with a diverse gut microbiome enriched in bacteria of the Ruminococcaceae family were more likely to respond to anti-PD-1 treatment. "In our current study, we wanted to look at how diet and supplements affect the microbiome and modulate responses to checkpoint immunotherapy," Spencer said. According to Spencer, this is the first clinical study to report results on the relationship between diet, the microbiome, and checkpoint blockade immunotherapy response.

Utilizing prospectively collected fecal samples from 113 melanoma patients starting treatment at the MD Anderson Cancer Center, the researchers characterized the diversity and type of bacterial species found in the gut microbiome. They found that higher microbiome diversity was associated with response to therapy regardless of treatment type and that the gut microbiome did not significantly differ based on age, sex, and body mass index (BMI).

Among patients who completed baseline dietary surveys, researchers found that eating whole grains, fruits and vegetables, and a high-fiber diet was positively associated with bacteria previously shown to confer response to anti-PD-1 treatment. Diets high in added sugars and processed meat were negatively associated with these bacteria.

In a subset of 46 patients treated with anti-PD-1 immunotherapy, the researchers found that patients who consumed a high-fiber diet were about five times as likely to respond to anti-PD-1 treatment compared to patients who consumed a low-fiber diet.

"We know from prior research that eating a higher-fiber diet has a lot of health benefits," Spencer said. "But with this preliminary research on cancer patients and the microbiome, it appears that fiber is also linked to a better response to immunotherapy."

Among all surveyed patients, more than 40 percent reported use of probiotic supplements, which was associated with lower gut microbiome diversity. Spencer noted that low gut microbiome diversity has been linked to poorer response to checkpoint inhibitor immunotherapy.

"There's a perception that taking probiotics improves gut health, but our results, although early, suggest that may not be the case for cancer patients," said Spencer.

Probiotics are not regulated by the U.S. Food and Drug Administration (FDA). "Based on these preliminary results, we need to reconsider use of over-the-counter probiotics in patients with cancer, at least until we have more data supporting their potential safety and efficacy," said senior author Jennifer Wargo, MD, MMSc, a Parker Institute investigator at MD Anderson, where she is an associate professor of surgical oncology and genomic medicine.

The research group will be presenting additional results at the meeting.

Limitations of the study include a small sample size and a reliance on self-reported diet and supplement use.

This study was sponsored by the Melanoma Research Alliance, the MD Anderson Melanoma Moonshot, the Miriam and Jim Mulva Research Fund, and the Miriam and Sheldon G. Adelson Medical Research Foundation. Wargo receives funding from the National Institutes of Health and Stand Up To Cancer.

Spencer and Wargo have contributed to a U.S. patent application (PCT/US17/53.717) that covers methods to enhance immune checkpoint blockade responses by modulating the microbiome.

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Dietary Factors Affecting Gut Microbiome May Influence Response to Immunotherapy in Melanoma Patients

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​PHILADELPHIA - Among melanoma patients treated with anti-PD-1 immunotherapy, consumption of a high-fiber diet was associated with higher gut microbiome diversity and better response to treatment, according to data presented during a media preview of the AACR Annual Meeting 2019, to be held March 29-April 3 in Atlanta."We found that diet and supplements appear to have an effect on a patient's ability to respond to cancer immunotherapy, most likely due to changes in their gut microbiome," said Christine Spencer, PhD, research scientist at the Parker Institute for Cancer Immunotherapy.

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This article supports resource center like Waterford as a valued patient support and assistance in their cancer tx program.