Diversity, Equity, Inclusion, and Accessibility in Cancer Care: A Synopsis of Literature From 2021 Through April 2023

Contemporary interest in the phenomenon of diversity, equity, inclusion, and accessibility (DEIA) has resulted in a plethora of literature on this topic specific to cancer. Oncology nurses need to be informed of these issues.

Clinical care in hepatocellular carcinoma: A mixed methods assessment of experiences and challenges of oncology professionals

INTRODUCTION

Healthcare providers (HCPs) may face numerous dilemmas in optimally screening, diagnosing, and treating patients with, and/or at risk for, hepatocellular carcinoma (HCC). This study aimed to achieve a greater understanding of the challenges in HCC care which in turn could delineate HCP educational opportunities within this oncologic sub-specialty.

METHODS

A mixed-methods approach was used to identify practice gaps and clinical barriers experienced by US-based medical oncologists, hepatologists, oncology physician assistants, oncology nurse practitioners, and interventional radiologists involved in HCC care. The qualitative (semi-structured interview) and quantitative (survey) data collection approaches were deployed sequentially with findings subsequently triangulated.

RESULTS

A total of 214 HCPs participated in this study. Analysis revealed challenges related to screening and diagnosing HCC, specifically in applying appropriate screening guidelines, and the optimal use and decisions related to diagnostic imaging and biopsy. Issues related to treatment selection included the application of existing HCC guidelines in treatment decision-making, weighing risk/benefit ratios of various antineoplastics regimens (i.e., tyrosine kinase inhibitors-TKIs, immunotherapy agents, chemotherapy), sequencing therapies, potential toxicity management, and optimally educating patients about their HCC.

CONCLUSION

These findings highlight the educational needs of those involved in HCC care and provide a starting point for clinicians to both reflect on their practice and identify opportunities to enhance communication within the HCC team and between provider and patient. There is an opportunity to optimize continuing professional development interventions that address the identified gaps in clinical practice specifically related to teamwork and interdisciplinary communication.

Contemporary Insights into Cancer Cachexia for Oncology Nurses

Cachexia is a complex, multiorgan phenomenon targeting skeletal muscle resulting from systemic metabolic imbalances. Multifocal in nature, It's ultimate outcome is significant muscle degradation and loss of adipose tissue exhibited as the "wasting syndrome" which is associated with significant functional decline. Currently, there are no approved biomarkers for screening nor therapeutic options to manage cancer cachexia. Furthermore, multiple psychosocial sequelae characterize the patient and family coping paradigm. Heightened education about the pathophysiology of cancer cachexia and awareness of intra-familial emotional distress can enhance oncology nurses' advocacy about, and attentiveness to, this common manifestation of advanced cancer.

Creating a Blueprint of Well-Being in Oncology: An Approach for Addressing Burnout From ASCO's Clinician Well-Being Taskforce

Optimizing the well-being of the oncology clinician has never been more important. Well-being is a critical priority for the cancer organization because burnout adversely impacts the quality of care, patient satisfaction, the workforce, and overall practice success. To date, 45% of U.S. ASCO member medical oncologists report experiencing burnout symptoms of emotional exhaustion and depersonalization. As the COVID-19 pandemic remains widespread with periods of outbreaks, recovery, and response with substantial personal and professional consequences for the clinician, it is imperative that the oncologist, team, and organization gain direct access to resources addressing burnout. In response, the Clinician Well-Being Task Force was created to improve the quality, safety, and value of cancer care by enhancing oncology clinician well-being and practice sustainability. Well-being is an integrative concept that characterizes quality of life and encompasses an individual's work- and personal health-related environmental, organizational, and psychosocial factors. These resources can be useful for the cancer organization to develop a well-being blueprint: a detailed start plan with recognized strategies and interventions targeting all oncology stakeholders to support a culture of community in oncology.

The COVID-19-Cancer Connection

I recently completed work at a large-scale, drive-through COVID-19 vaccination initiative and was immediately struck by its military parallel in mobilizing this emergent medical response. Federal personnel were deployed quickly to assist the local workforce untested in a public health domain. The expansive integration of technology was at a level I had not previously witnessed. Computerized algorithms organized the flow of cars through a huge fairground (think Disneyland Park). Databases were created to register the public, make appointments, and document the specifics of vaccination administration. From day one, the pharmacy tent was in constant overdrive to ensure vaccine supply was in sync with hourly demand. The interface of all these platforms vaccinated 2,300 people per day.

Nursing Care at the End of Life: Optimizing Care of the Family in the Hospital Setting

Most Americans prefer their home as a place of death, but most die in the hospital acute care setting. Nurses are the major providers of hospital-based end-of-life care; therefore, it is imperative to identify family preferences for nursing support during the end of life. An initiative was undertaken to create a blueprint for operationalizing research findings that identified family preferences for nursing support during the peri-death experience of a loved one within acute care. Seven components of an acute bereavement support protocol were delineated: developing room signage, assessing family prioritization parameters of support measures, offering advice on saying goodbye, performing an honoring ceremony, creating a memory keepsake, escorting the family out of the hospital, and sending a sympathy card following the loved one's death.

Foundations of Practice

A highly disproportionate burden of cancer is manifested in the world's poorest societies. Since 2016, I have volunteered with the Washington, DC-based organization Health Volunteers Overseas and have provided oncology and palliative nursing education and consultation in Vietnam, Honduras, and Bhutan. In addition, I have volunteered with Living Room International in Kenya, focusing on hospice nursing resource enhancement. I have traveled more than 50,000 miles to those four resource-impoverished nations and witnessed hardships beyond description.

Burnout, Moral Distress, Work-Life Balance, and Career Satisfaction among Hematopoietic Cell Transplantation Professionals

A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identified as a major issue during the National Marrow Donor Program/Be The Match System Capacity Initiative. Work-related distress and work-life balance were noted to be potential barriers to recruitment/retention. This study examined these barriers and their association with career satisfaction across HCT disciplines. A cross-sectional, 90-item, web-based survey was administered to advanced practice providers, nurses, physicians, pharmacists, and social workers in 2015. Participants were recruited from membership lists of 6 professional groups. Burnout (measured with the Maslach Burnout Inventory subscales of emotional exhaustion and depersonalization) and moral distress (measured by Moral Distress Scale-Revised) were examined to identify work-related distress. Additional questions addressed demographics, work-life balance, and career satisfaction. Of 5759 HCT providers who received an individualized invitation to participate, 914 (16%) responded; 627 additional participants responded to an open link survey. Significant differences in demographic and practice characteristics existed across disciplines (P < .05). The prevalence of burnout differed across disciplines (P < .05) with an overall prevalence of 40%. Over one-half of pharmacists had burnout, whereas social workers had the lowest prevalence at less than one-third. Moral distress scores ranged from 0 to 336 and varied by discipline (P < .05); pharmacists had the highest mean score (62.9 ± 34.8) and social workers the lowest (42.7 ± 24.4). In multivariate and univariate analyses, variables contributing to burnout varied by discipline; however, moral distress was a significant contributing factor for all providers. Those with burnout were more likely to report inadequate work-life balance and a low level of career satisfaction; however, overall there was a high level of career satisfaction across disciplines. Burnout, moral distress, and inadequate work-life balance existed at a variable rate in all HCT disciplines, yet career satisfaction was high. These results suggest specific areas to address in the work environment for HCT health professionals, especially the need for relief of moral distress and a greater degree of personal time. As the creation of healthy work environments is increasingly emphasized to improve quality care and decrease costs, these findings should be used by HCT leadership to develop interventions that mitigate work-related distress and in turn foster recruitment and retention of HCT providers.

The Caregiving Quandary

Long before I became a cancer caregiver, I worried about families. Providing care without a script, expanding their workload, solo decision making, incessant worrying, managing expectations, overseeing medications-that is the lay caregiver's all-consuming world. However, when cancer entered my residence, I started living what I had historically observed from a distance. The double-duty caregiving at work and home overwhelmed me. Years of experience did little to prepare me for the emotional tsunami and physical toll caregiving took on me. I questioned my ability to make decisions, I got my husband's medications mixed up, and I had trouble asking for and accepting help, despite how much I needed it.
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Hepatocellular Carcinoma: Implications for Asia-Pacific Oncology Nurses

Hepatocellular carcinoma (HCC) is a prominent malignancy in the Asia-Pacific region. Despite considerable knowledge about it's scope and nature this malignancy remains incurable. This manuscript reviews the epidemiology of this cancer, its pathogenesis, risk factors, potential prevention, surveillance, treatment, and the oncology nurses’ role relative to this malignancy. A literature search from the past decade was performed using the PubMed and CINAHL databases using the search terms “hepatocellular carcinoma,” “Asia,” and “nursing issues”. Themes such as etiology, prevention, treatment, and prognosis were included in this synthesis which has particular relevance to oncology nurses within the Asia-Pacific region.

Argatroban therapy in pediatric patients requiring nonheparin anticoagulation: an open-label, safety, efficacy, and pharmacokinetic study

BACKGROUND

An increasing number of pediatric patients suffer from thrombotic events necessitating anticoagulation therapy including heparins. Some such patients develop heparin-induced thrombocytopenia (HIT) and thus require alternative anticoagulation. As such, studies evaluating the safety, efficacy, and dosing of alternative anticoagulants are required.

PROCEDURE

In this multicenter, single arm, open-label study, 18 patients ≤ 16 years old received argatroban for either a suspicion of or being at risk for HIT, or other conditions requiring nonheparin anticoagulation. Endpoints included thrombosis, thromboembolic complications, and bleeding.

RESULTS

Patients (ages, 1.6 weeks to 16 years) received argatroban usually for continuous anticoagulation (n = 13) or cardiac catheterization (n = 4). One catheterization patient received a 250 µg/kg bolus only; 17 patients received argatroban continuous infusion (median (range)) 1.1 (0.3-12) µg/kg/min (of whom four received a bolus) for 3.0 (0.1-13.8) days. In patients without bolus dosing, typically argatroban 1 µg/kg/min was initiated, with therapeutic activated partial thromboplastin times (aPTTs) (1.5-3× baseline) achieved within 7 hr. Within 30 days, thrombosis occurred in five patients (two during therapy). No one required amputation or died due to thrombosis during therapy. Two patients had major bleeding. Pharmacometric analyses demonstrated the optimal initial argatroban dose to be 0.75 µg/kg/min (if normal hepatic function), with dose reduction necessary in hepatic impairment.

CONCLUSIONS

In pediatric patients requiring nonheparin anticoagulation, argatroban rapidly provides adequate levels of anticoagulation and is generally well tolerated. For continuous anticoagulation, argatroban 0.75 µg/kg/min (0.2 µg/kg/min in hepatic impairment), adjusted to achieve therapeutic aPTTs, is recommended.

Countering compassion fatigue: a requisite nursing agenda

Nurses have a longstanding history of witnessing the tragedy experienced by patients and families; however, their own reactions to profound loss and premature death have not been systematically addressed. There is a paucity of research describing interventions to prevent or minimize the ramifications of repeated exposure to traumatic events in the clinical workplace. Compassion fatigue is a contemporary label affixed to the concept of personal vicarious exposure to trauma on a regular basis. Yet this phenomenon of compassion fatigue lacks clarity. In this article, the author begins by describing compassion fatigue and distinguishing compassion fatigue from burnout. Next she discusses risk factors for, and the assessment of compassion fatigue. The need to support nurses who witness tragedy and workplace interventions to confront compassion fatigue are described.

The invisibility of nursing: implications from an analysis of National Cancer Institute-designated comprehensive cancer center web sites

PURPOSE/OBJECTIVES

To identify the degree of oncology nursing representation on public Web sites of the National Cancer Institute (NCI)-designated comprehensive cancer centers (CCCs) in the United States.

DESIGN

Qualitative, descriptive.

SETTING

Web sites.

SAMPLE

40 CCCs.

METHODS

Using the Google search engine, a query was undertaken using the term National Cancer Institute-designated comprehensive cancer center. The search resulted in linkage to the site www.cancer.gov, which provided Web site addresses for 40 CCCs. The CCCs were classified into five categories based on the degree of nursing representation evident throughout each Web site.

MAIN RESEARCH VARIABLES

Presence and quality of four themes in the Web site specific to oncology nursing activity at the CCC: (a) recognition of nursing on the CCC home page; (b) citations and/or descriptions of nursing personnel, programs, or recognitions within the Web site; (c) existence of a dedicated nursing Web page; and (d) acknowledgment of the chief nursing officer at the CCC.

FINDINGS

Only 2 of the 40 CCCs revealed broad representation of oncology nursing throughout their Web site. Nearly 63% of CCC Web sites had no or minimal content about nursing.

CONCLUSIONS

Public Web sites offer important information to patients with cancer, their families, and the general public. The absence of nursing in lay-oriented media devalues oncology nurses' highly specialized knowledge and skill.

IMPLICATIONS FOR NURSING

Considerable opportunity exists to enhance the public's awareness of the scope and complexity of contemporary oncology nursing within the 40 CCCs in the United States. Omission of positive messages about nurses' work in hospital-related media misleads the public that nurses are not integral members of the multidisciplinary team. With the continued absence of both descriptive and results-oriented work quantification, oncology nurses will remain unable to communicate their worth to the public, nor take credit for their care.

Delirium in Older Adults With Cancer: Implications for Practice and Research

PURPOSE/OBJECTIVES

To provide a comprehensive review of the literature and existing evidence-based findings on delirium in older adults with cancer.

DATA SOURCES

Published articles, guidelines, and textbooks.

DATA SYNTHESIS

Although delirium generally is recognized as a common geriatric syndrome, a paucity of empirical evidence exists to guide early recognition and treatment of this sequelae of cancer and its treatment in older adults. Delirium probably is more prevalent than citations note because the phenomenon is under-recognized in clinical practice across varied settings of cancer care.

CONCLUSIONS

Extensive research is needed to formulate clinical guidelines to manage delirium. A focus on delirium in acute care and at the end of life precludes identification of this symptom in ambulatory care, where most cancer therapies are used. Particular emphasis should address the early recognition of prodromal signs of delirium to reduce symptom severity.

IMPLICATIONS FOR NURSING

Ongoing assessment opportunities and close proximity to patients' treatment experiences foster oncology nurses' mastery of this common exemplar of altered cognition in older adults with cancer. Increasing awareness of and knowledge delineating characteristics of delirium in older patients with cancer can promote early recognition, optimum treatment, and minimization of untoward consequences associated with the historically ignored example of symptom distress.

Depression in patients with advanced cancer

Sadness is a normal reaction to the fears, anxieties, and uncertainties during any stage of cancer but is especially problematic during the advanced stage. Depressive symptoms and syndromes frequently coexist during this time and affect quality of life. Depression is an overlooked and undertreated symptom during late-stage cancer. This article provides an overview of the epidemiology, neurophysiology, diagnostic and screening approaches, risk factors, and treatment modalities for depression in patients with advanced cancer.

Psychological adjustment to the melanoma experience

OBJECTIVES

To provide a review of the literature on the psychological adjustment to malignant melanoma.

DATA SOURCES

Research reports and review articles.

CONCLUSIONS

Three prominent themes evolved from the literature: (1) delineation of issues concerning long-term survivorship and quality of life following a diagnosis of melanoma; (2) coping with metastatic and end-stage melanoma; and (3) identification of the possible link between immunomodulation and the evolution of melanoma.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses must individualize their support and counsel according to the potential trajectory of the patient's melanoma experience. Nurses need to identify an individual's risk for psychological distress and help them enhance coping skills.

Medication misadventure in cancer care

OBJECTIVES

To describe the nature and scope of the problem of medication errors in health care, with specific implications for error reduction and prevention.

DATA SOURCES

Articles and research studies.

CONCLUSIONS

Because of the complexity of chemotherapeutic regimens, requirements for supportive care drugs, and the physiologic vulnerability of patients due to their malignancies and intensive therapies, patients with cancer should be the focus of interdisciplinary medication error prevention programs.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a critical role in patient safety and the implementation of preventive and risk-reducing interventions to improve the drug delivery process.

The effect of low-dose cimetidine (200 mg twice daily) on the pharmacokinetics of theophylline

The potential for nonprescription cimetidine (200 mg twice daily) to affect the pharmacokinetics of sustained-release (SR) theophylline was assessed in 26 male subjects, 13 smokers and 13 nonsmokers. This was a concentration-controlled drug interaction study in which the subjects were administered a dose of SR theophylline every 12 hours to provide a mean steady-state concentration between 8 and 15 micrograms/ml. To determine individual theophylline dose, a test dose of aminophylline was administered, and baseline theophylline pharmacokinetics were determined. Subjects remained on SR theophylline for 23 days and were treated in the following sequence: run-in phase (4 days), treatment 1 (7 days), washout (5 days), and treatment 2 (7 days). During the treatment phases, subjects received cimetidine (200 mg at approximately 08:00 and 12:00) or placebo for 7 days in a randomized crossover fashion. Theophylline pharmacokinetics were determined on days 1, 4, and 7 of both treatment phases. A large day-to-day variability in the oral clearance of theophylline was evident for the theophylline-placebo treatment and the theophylline-cimetidine treatment. Nonprescription strength cimetidine resulted in a mean 5% decrease in theophylline oral clearance on day 1 and a mean 12% decrease on days 4 and 7 combined. There were no significant differences in the cimetidine-theophylline interaction between smokers and nonsmokers. Oral clearance during the nighttime dosing interval was 13% greater than the daytime oral clearance for nonsmokers and 22% greater for smokers, showing a greater circadian rhythm for smokers. In summary, nonprescription doses of cimetidine (400 mg/day) have the potential to produce small changes in theophylline concentrations during steady-state dosing with SR theophylline; however, this effect appears less than changes that occur as a consequence of theophylline's intrasubject variability.

The pharmacokinetics of carvedilol and its metabolites after single and multiple dose oral administration in patients with hypertension and renal insufficiency

INTRODUCTION

Carvedilol, a chiral compound possessing nonselective beta- and alpha1-blocking activity, is used for the treatment of hypertension and congestive heart failure (CHF). The enantiomers of carvedilol exhibit similar alpha1-blocking activity; only S-carvedilol possesses beta-blocking activity. Carvedilol is primarily hepatically metabolized, with less than 2% of the dose excreted renally as unchanged drug.

METHODS

The pharmacokinetics of carvedilol, R-carvedilol, and S-carvedilol were studied in hypertensive patients (control; n = 13) versus patients with hypertension and advanced renal insufficiency not yet on dialysis [GFR < or = 30 ml x min(-1) (CRI, chronic renal insufficiency), n = 12] following single (12.5 mg, Day 1) and multiple (25 mg once daily, Days 2 9) dosing.

RESULTS

Mean with (SD) AUC(0-24h) (ng x h x ml(-1)) for carvedilol was 220 (120) and 618 (335) in CRI compared with 165 (83.5) and 413 (247) in controls on Days 1 and 9, respectively, primarily due to higher R-carvedilol concentrations. Mean with (SD) Cmax (ng x ml(-1)) for carvedilol were 53.4 (31.4) and 128 (63.3) in CRI compared with 46.7 (23.3) and 104 (58.9) in controls on Days 1 and 9, respectively. The difference in group mean values was characterized by considerable overlap in individual AUC(0-24h) and Cmax values between groups. There was no apparent difference in mean terminal elimination half-life for carvedilol between groups on each study day. Less than 1% of the dose was excreted in urine as unchanged carvedilol in both groups. Blood pressure and heart rate declined in both groups to a similar degree.

CONCLUSION

Compared with controls, average AUC(0-24 h) values for carvedilol were approximately 40% and 50% higher on study Days 1 and 9 in patients with renal insufficiency, primarily due to higher R-carvedilol concentrations with only a small change (<20%) in S-carvedilol concentrations, the isomer possessing beta-blocking activity. These changes in pharmacokinetics are modest in view of the large interindividual variability. Carvedilol was well tolerated in both groups. Although the present study cannot provide a final conclusion, based on the results of the present study, no changes in dosing recommendations for carvedilol are warranted in patients with moderate/severe renal insufficiency.

Lymphoma at the extremes of age

OBJECTIVES

To provide a review of the unique features of both Hodgkin's and non-Hodgkin's lymphoma in pediatric and geriatric patient populations. Treatment approaches and nursing care interventions at the extremes of age will be discussed.

DATA SOURCES

Review articles, research studies, and book chapters.

CONCLUSIONS

Lymphoma is a highly heterogeneous malignancy whose classification and management have undergone significant evolution. Of particular concern has been lymphoma's prevalence and treatment at the extremes of age. Appropriate treatment by age and subtype remains controversial.

IMPLICATIONS FOR NURSING PRACTICE

The nursing care of pediatric and geriatric patients with lymphoma presents numerous challenges in education, symptom management, and supportive care.

A review of paclitaxel (Taxol) administration, stability, and compatibility issues

The purpose of this article is to review information relative to the administration, stability, and compatibility of paclitaxel (Taxol, Mead Johnson Oncology Products, Princeton, NJ). The unique formulation used to solubilize paclitaxel has led to an increased awareness of plasticizer-leaching issues, paclitaxel stability in solution, and paclitaxel compatibility with other medications. Particularly with longer paclitaxel infusion schedules (greater than 48 hours), both drug stability in solution and pump apparatus congruence require careful consideration to minimize plasticizer-leaching problems and to ensure optimum drug delivery. Despite knowledge of the physical compatibility of paclitaxel with numerous drugs, a paucity of research has documented the specifics of paclitaxel's chemical compatibility with other medications.