You are here: Home: LCU Nurses Vol 1 Issue 1 : Editor's office
 |
Editor’s Note |
|
| A paradigm shift in oncology nursing |
One of the most common clinical presentations of lung cancer is a 65- to 75-year old former smoker who is having significant respiratory symptoms from metastatic non-small cell carcinoma. Combination chemotherapy is usually administered in these cases, but the patient will generally die of the disease in less than a year.
Clearly there are many exceptions to this prototypical situation. There is the uncommon patient with localized disease who is “cured” with surgery and the patient with locally advanced disease who is treated with a combination of chemotherapy and radiation therapy. Also, a small fraction of patients are nonsmokers. However, when viewing the most typical presentation, a number of challenges must be faced by the treatment triad — patient, nurse and physician:
1. Should systemic therapy be administered and, if so, what type?
Many lung cancer patients have smoking-induced, underlying, comorbid cardiorespiratory conditions that increase the likelihood of chemotherapyrelated toxicity. While the commonly utilized carboplatin-containing combinations introduce less toxicity than cisplatin-based regimens, there is considerable risk that an already symptomatic patient will feel worse after treatment. On the other hand, if tumor response occurs and treatment side effects are minimized, the patient’s quality of life is likely to improve, at least temporarily.
Another consideration in lung cancer management is the use of targeted therapies, which tend to induce relatively minimal side effects. The only such treatment currently available outside a trial setting is the orally administered tyrosine kinase inhibitor, gefitinib (Iressa®), which results in symptomatic improvement in perhaps 40 percent of patients with non-small cell lung cancer. Skin rash and diarrhea are the most common side effects, but most patients find this approach much more convenient and less toxic than chemotherapy.
2. Can the patient participate in a clinical trial?
Patients may wish to consider participation in a clinical trial to help both themselves and future patients. One man interviewed for this program is part of a fascinating study involving a vaccine formulated from his own tumor cells. These intradermal injections are well-tolerated and no side effects have been observed.
Exciting new therapies like gefitinib are only available because patients were provided with the option of clinical trial participation. The initial gefitinib trials revealed that this agent is more effective when it is given alone than if combined with chemotherapy — a finding many did not anticipate. In this program, Dr Paul Bunn outlines how he uses gefitinib and discusses the many other recent advances in clinical research that are now providing better options for patients. Ms Susie Lehnerz, a research coordinator for the thoracic oncology division of the University of Colorado, provides an overview of the many different studies now available. Participation in these trials not only offers perhaps closer follow-up for patients but also the opportunity to improve future lung cancer treatment.
3. How can guilt and self-blame for this condition be ameliorated?
For the last two decades, smokers have increasingly been isolated from the rest of our society. Family members and friends often show a lack of compassion for the cruelty of nicotine addiction, and smokers are hounded to quit. In fact, while smoking accounts for at least 90 percent of lung cancers, most patients have already quit when diagnosed.
This is a brutal background to face a disease that is often relentless, and patients regularly struggle to avoid despair and self-recrimination. In this program, oncology nurse Ms Tina Russell verbalizes her contempt for healthcare professionals who consider people with lung cancer second-class cancer patients because “they did it to themselves.” Ms Russell allows her patients the opportunity to express regret or remorse for smoking and then helps them focus their energies on combating the disease. |
In preparing to launch this series, we invited Ms Karen Stanley, incoming president of the Oncology Nursing Society, to spend a day with our education team in Miami. She shared with us her vision of a paradigm shift in oncology nursing in which the nurse will become much more involved from the first clinical encounter by assessing and intervening in the patient’s entire panorama of biopsychosocial concerns.
Her belief is that early in the patient’s interaction with the oncology office, nurses are primarily focused on the delivery of parenteral medications. Deeper involvement in quality-of-life issues may not occur until the end stage of the disease. Ms Stanley believes this needs to change.
In reviewing the three commonly encountered clinical dilemmas noted above, it is clear that the oncology nurse can take a leadership role in understanding the entire biopsychosocial spectrum of the newly diagnosed lung cancer patient and in determining how, for example, systemic therapy or clinical trial participation fits in.
In my view, the nurse is also the oncology team member most likely to detect emotional concerns like remorse about smoking. In this program, interviews with three lung cancer patients and one spouse reveal many issues that oncology nurses can assess and manage, including:
- Discussions and interactions with family members
- Problems in transportation to the clinic visit
- Inconveniences of office visits and treatment administration and their effect on lifestyle
- Spiritual or religious support
- Effects of a fulminant disease course on a family and a marriage
This leadership role of the oncology nurse is already a reality in many oncology settings. Ms Russell clearly embraces this responsibility. In the next issue of our series, Ms Anne Culkin from Memorial Sloan-Kettering Cancer Center in New York tells us that she — and not her oncologist partner, Dr Mark Kris — is the first person to evaluate new patients in their lung cancer clinic.
I am curious about how oncology nurses on the clinical front lines feel about this paradigm shift that will form the focal point of Ms Stanley’s term as president of the ONS. Is her hope realistic in view of the many other responsibilities of oncology nurses? Is this concept already a reality? Will all or most patients benefit from this approach or should there be some selection involved? I encourage you to email me your thoughts and reactions. We will share your insights with Ms Stanley and publish some of them in upcoming issues.
— Neil Love, MD
NLove@ResearchToPractice.net
Select publications
Bakas T et al. Caregiving tasks among family caregivers of patients with lung cancer. Oncol Nurs Forum 2001;28(5):847-54. Abstract
Bell RM, Tingen MS. The impact of tobacco use in women: Exploring smoking cessation strategies. Clin J Oncol Nurs 2001;5(3):101-4. Abstract
Bredin M et al. Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. BMJ 1999;318(7188):901-4. Abstract
Browning KK et al. Implementing the Agency for Health Care Policy and Research’s Smoking Cessation Guideline in a lung cancer surgery clinic. Oncol Nurs Forum 2000;27(8):1248-54. Abstract
Cooley ME et al. Challenges of recruitment and retention in multisite clinical research. Cancer Nurs 2003;26(5):376-84. Abstract
Hamilton J et al. The impact and management of cancer-related fatigue on patients and families. Can Oncol Nurs J 2001;11(4):192-8. Abstract
Krishnasamy M et al. Cancer nursing practice development: Understanding breathlessness. J Clin Nurs 2001;10(1):103-8. Abstract
Kuo TT, Ma FC. Symptom distresses and coping strategies in patients with non-small cell lung cancer. Cancer Nurs 2002;25(4):309-17. Abstract
Martin K et al. Women’s initiative for nonsmoking (WINS) II: The intervention. Heart Lung 2000;29(6):438-45. Abstract
Moore S et al. Nurse led follow up and conventional medical follow up in management of patients with lung cancer: Randomised trial. BMJ 2002;325(7373):1145. Abstract
Tishelman C et al. Measuring symptom distress in patients with lung cancer. A pilot study of experienced intensity and importance of symptoms. Cancer Nurs 2000;23(2):82-90. Abstract
|
