The Annual Meeting of the American Society of Clinical Oncology (ASCO) is the largest and most important oncology specialty meeting in the United States, and arguably the world. More than 30,000 oncology professionals gathered in Chicago, IL, to hear about ground-breaking research, state-of-the-art treatment modalities, new therapies, and ongoing controversies in the field. Below is a selection of presentations from oral abstracts, posters, and the ASCO education sessions that will be of interest to oncology nurses and advanced practitioners.
More than 200 interventional trials have been conducted to evaluate the role of physical exercise in cancer patients, but to date there are no randomized controlled trials to provide level 1 evidence that physical exercise affects outcomes, explained Kerry S. Courneya, PhD, University of Alberta, Edmonton, Canada, at an ASCO education session.
Most of the evidence for the benefits of physical exercise comes from systematic reviews of studies in the survivorship phase showing reduced fatigue and improved quality of life. All the existing literature shows that outcomes are improved with supervised interventions, but it is not clear that supervised exercise sessions will be incorporated into clinical practice or who will pay for these sessions. Reimbursement is a big problem.
Changing patients’ behavior is the most challenging goal to achieve. Using the Diabetes Prevention Program/Look AHEAD trial as a model, several strategies can be adapted to promote behavioral change in patients with cancer. Key elements include face-to-face sessions with qualified staff, supervised exercise sessions, clear and challenging exercise goals, behavior modification techniques, intensive and ongoing contact, written materials to supplement advice, individual tailoring of intervention, and a theoretical model of behavior change.
The CHALLENGE trial seeks to effect behavioral change related to physical activity and diet in colon cancer patients. This ongoing study has demonstrated the feasibility of incorporating: a colon cancer–specific exercise guidebook, supervised exercise sessions, 14 face-to-face counseling sessions, telephone counseling sessions, tapering contact (weekly to biweekly to monthly), and free/low-cost access to a fitness facility. Oncologists and advanced practitioners should become advocates for supervised exercise oncology programs at their centers or clinics, if feasible, or have an exercise consultant to refer patients to. If this is not feasible, patients should be referred to supervised exercise programs where available.
“Recommend exercise to your patients. Provide written exercise materials to patients. Support exercise research studies if available,” Courneya told listeners.
“In summary, there is good evidence suggesting that physical exercise improves outcomes in cancer patients, but it needs to be supervised and appropriately prescribed and delivered. Supervised programs seem to be the best way of prescribing and delivering exercise. Research is ongoing to find the best ways to deliver these interventions,” he stated.
Reference Courneya KS. Physical activity: interventions and practical considerations. Presented at: 51st Annual Meeting of the American Society of Clinical Oncology; May 29-June 2, 2015; Chicago, IL.
A single dose of intravenous (IV) fosaprepitant added to a 5-HT3 receptor antagonist (ondansetron) and corticosteroid (dexamethasone) achieved superior control of chemotherapy-induced nausea and vomiting (CINV) in patients treated with moderately emetogenic chemotherapy (MEC) in a randomized, double-blind, placebo-controlled study.
“Based on these results, the single-dose IV fosaprepitant 150-mg regimen may reduce the need for multiday antiemetic therapy in the prevention of CINV associated with MEC,” stated the authors. Bernardo L. Rapoport, MD, of the Medical Oncology Centre of Rosebank, Johannesburg, South Africa, was lead author of this study, which was sponsored by Merck Sharp & Dohme.
The global trial enrolled 1015 patients with confirmed cancer treated with MEC (excluding adriamycin/cyclophosphamide) who were randomized to receive fosaprepitant/ondansetron 8 mg/dexamethasone 12 mg versus placebo/ondansetron 8 mg/dexamethasone 12 mg. An intent-to-treat analysis, based on 1000 evaluable patients, found a significant difference in the rate of complete response (CR) to antiemetic therapy favoring the experimental arm over the control arm: 78.9% versus 68.5%, respectively, for a 10.4% difference (P <.001). During the overall phase, these results remained similar between the 2 arms, with CR rates of 77.1% versus 66.9%, respectively (P <.001). During the acute phase, CR was achieved by more than 90% in each group, with no significant difference.
The fosaprepitant group had a significantly greater proportion of patients with no vomiting in the overall and delayed phases (both, P <.001 vs control) with a favorable trend in the acute phase. The types and frequency of adverse events were comparable between both groups, and were typical of cancer patients treated with MEC. The most commonly reported adverse events (>10% of the study population) were fatigue (15.1% for fosaprepitant vs 12.9% for controls), diarrhea (12.7% vs 11.3%, respectively), and constipation (9.3% vs 10.5%, respectively). Of the 16 deaths that occurred during the trial (10 occurred between days 1 and 17 of the trial), all were deemed attributable to the underlying cancer, other preexisting conditions, or the patient’s response to chemotherapy; none were judged to be related to the study drug.
Baseline demographic and disease characteristics were similar between the 2 treatment arms. Median age was around 60 years, about 80% were age 50 years or older, more than half were female, and about 70% were on single-day chemotherapy regimens. About 25% had lung cancer, 23% had breast cancer, 20% had colorectal cancer, 15% had gynecologic cancer, 7.4% had gastrointestinal cancer, and the remaining patients had other cancer types.
Reference Rapoport BL, Weinstein C, Camacho ES, et al. A phase III, randomized, double-blind study of single-dose intravenous fosaprepitant in preventing chemotherapy-induced nausea and vomiting associated with moderately emetogenic chemotherapy. Presented at: 51st Annual Meeting of the American Society of Clinical Oncology; May 29-June 2, 2015; Chicago, IL. Abstract 9629.
Now that new tests are changing the landscape of genetic testing, challenges are emerging in communicating results to patients, according to presenters at an ASCO education session on “Genetic Testing in 2015: Who Owns the Data, How Do You Return Results, and Other Clinical Dilemmas.”
Multigene panels can now be offered to patients, and these allow the testing of many genes for the same price as testing for 1 or 2 genes. Although this allows detection of mutations that contribute to hereditary cancers, many genes included in the panel are not actionable (treatable), and their exact contribution to cancer risk remains unknown. The detection of unclassified genetic variants is common.
How to explain all this to patients? Wendy Kohlmann, MS, CGC, Huntsman Cancer Institute, University of Utah, said that providers can help prepare patients to receive and understand results with appropriate pretest counseling. Patients need to be educated about potential findings from multigene panels and the difference between high-risk and moderate-risk genes, she said. When these discussions are part of counseling, patient expectations can be appropriately managed. Moreover, once patients understand that multigene panels can convey information that does not help in their treatment, they may opt for testing only high-risk genes based on family history.
Unexpected results can turn up on multigene panel testing; for example, a patient may want to know whether she has BRCA1 or BRCA2 mutations based on breast or ovarian cancer history of her first-degree relatives, and the test could identify a gene such as CDH1, which is associated with a high risk of developing gastric cancer. A finding like this raises a host of difficult questions, including whether this mutation conveys the same risk in a carrier without a family history of gastric cancer as in one without such a history, and if the patient wants to pursue her gastric cancer risk when that was not her initial concern.
“The pretest counseling prepares patients for the possible outcomes of testing. One cannot separate preparing the patient from returning the results,” she told listeners. “It is all one process because the pretest visit helps prepare patients, and this determines the outcome of the disclosure.”
Genetic counselors are a helpful resource in addressing these needs in the setting of a busy practice, she added.
Reference Kohlmann W. Role of the genetic counselor in returning genetic information. Presented at: 51st Annual Meeting of the American Society of Clinical Oncology; May 29-June 2, 2015; Chicago, IL.
Cancer patients are already disturbed and often devastated by their diagnosis, and a new study provides the first evidence that severe financial distress due to out-of-pocket costs of their treatment (sometimes referred to as “financial toxicity”) increases their risk of dying by 79%.
“We found a consistent, positive association between bankruptcy filing and higher mortality risk across individual cancers,” said lead author Aasthaa Bansal, PhD, University of Washington, Seattle.
“Dr Bansal’s study adds a major item to...a growing list of evidence-based financial toxicities that our patients experience because of the treatments we prescribe....I hope it prompts us to move beyond describing the problem of financial toxicity and actually intervening,” stated S. Yousuf Zafar, MD, Duke University School of Medicine, Durham, NC, formal discussant of this abstract. Zafar is one of the pioneers in the field of financial toxicity, and he and others argue that it should be considered as an adverse event in clinical trials.
Previous data showed that people with cancer are about 2.5 times more likely to become bankrupt than people without cancer, yet providers often fail to address financial issues during their visits with patients. The study was based on Surveillance, Epidemiology, and End Results (SEER) cancer registry data and federal bankruptcy records in western Washington from 1995 to 2009. Among 239,596 people aged 21 years or older who were diagnosed with cancer during this period, slightly more than 2% filed for bankruptcy. People who filed for bankruptcy were more likely to be younger age at diagnosis, female, and nonwhite, and have local or regional disease at diagnosis.
To adjust for confounding factors, Bansal and colleagues utilized propensity score matching to eliminate selection bias and enable a true comparison between the 2 groups according to baseline socioeconomic and cancer characteristics. The adjusted hazard ratio for mortality in cancer patients for bankruptcy versus nonbankruptcy was 1.79 (95% CI [1.64-1.96]; P <.001). A similar association was evident separately for breast, colorectal, lung, and prostate cancer. These associations persisted after excluding patients with distant-stage disease at diagnosis. Bansal believes that the mortality risk estimates may be conservative because bankruptcy represents the extreme end of the spectrum of financial distress. People in the nonbankruptcy group could also have lesser degrees of financial distress not captured by this arbitrary designation.
This is an observational study, with all the limitations that encompasses. Future study is needed to find factors that explain this association further and that could mitigate mortality risk.
Reference Bansal A, Ramsey SD, Fedorenko CR, et al. Financial insolvency as a risk factor for mortality among patients with cancer. Presented at: 51st Annual Meeting of the American Society of Clinical Oncology; May 29-June 2, 2015; Chicago, IL. Abstract 6509.
Burnout is common in oncology professionals, which is not surprising considering that they are often treating patients in pain who may be near death. One survey of oncologists found that 45% met criteria for burnout on the emotional exhaustion and/or depersonalization domain of the Maslach Burnout Inventory. Oncology nurses often experience burnout as well, for similar reasons, and nurses are particularly susceptible to this early in their career because of added pressure to perform and being faced with patients in distress. Burnout was addressed in an education session, “Burnout in Oncology Health Care Providers: Identifying Silent Despair and Maintaining Purpose.”1,2
“It is more important than ever to recognize burnout because it can lead to staff turnover, reduction of hours, quitting the profession, and negative personal consequences,” said Anthony Back, MD, Seattle Cancer Alliance, WA.
Early signs of burnout include irritability, not feeling recharged after time away from work, and the feeling that work totally consumes your life. Burnout can come and go; it is a fluid state, more prominent at some times than others. “Not only is it important to recognize burnout early, but also that there are things you can do about it,” Back stated.
Cynda H. Rushton, PhD, RN, Johns Hopkins University, Baltimore, MD, focused on burnout in oncology nurses. Nurses are frequently unprepared to manage issues in their practice, and this catches them unaware. “Being clinically competent doesn’t necessarily mean that we have all the personal tools we need to navigate the complex issues in oncology practice, especially with burgeoning technology and treatments that increase survival but threaten the quality of life of patients they help,” she said.
Nursing burnout leads to physical, emotional, relational, and spiritual suffering and can cause nurses to feel loss of meaning in their work. The scope of the problem of burnout is being increasingly recognized in cancer professionals, and several strategies can be helpful.
All of these are good suggestions, but the work environment needs to be supportive to implement these suggestions. Some hospitals and cancer centers provide special R&R retreats to combat burnout. Hospitals and healthcare systems are seeking effective solutions and resources that truly make a difference.
References 1. Back A. Burnout: what it is and why it matters. Presented at: 51st Annual Meeting of the American Society of Clinical Oncology; May 29-June 2, 2015; Chicago, IL. 2. Rushton CH. Moral distress as a source of burnout. Presented at: 51st Annual Meeting of the American Society of Clinical Oncology; May 29-June 2, 2015; Chicago, IL.
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