Author: Lam Choi Hung, Carol
Affiliations: Breast Cancer Case Manager, Pamela Youde Nethersole Eastern Hospital, Hong Kong
Author: Gillian Blanchard
Affiliations: Conjoint Lecturer School of Nursing and Midwifery, University of Newcastle, Australia
MASCC 2016 brought together over 1070 delegates from 50 counties to Adelaide, South Australia.
The meeting’s motto is “supportive care makes excellent cancer care possible” and was held over 4 days from the 22nd to the 24th of June. It featured a pre-conference cancer nurse practitioner workshop and patient seminar; six pre-conference Study Group workshops (mucositis research, nutritional care in advanced cancer, supportive care and immunotherapy, end of life, cancer related cognitive impairment and sleep, drowsiness and fatigue), plenary sessions on survivorship, gastrointestinal toxicity, and the future of supportive care, a patient seminar, e-posters, and a parallel paper session for each MASCC Study Group.
ISNCC hosted a display at the conference; this provided Australian ISNCC members an opportunity to promote the work of ISNCC and the benefits of membership.
The Cancer Nurse Practitioner pre- conference workshop was organized by the Cancer Nurses Society of Australia Nurse Practitioner Specialist Practice Network (CNSA CNP SPN). This event was designed for Cancer Nurse Practitioners and Advanced Clinicians. The program incorporated plenary presentations and Supportive Care Interactive Learning Sets (SCILS) and was attended by 53 delegates.
The plenary sessions featured local and international speakers Prof Dorothy Keefe: Supportive care challenges, Dr Karen Mustian: Exercise oncology from behavior to biology – Treating cancer-related fatigue, Tracey Doherty: The role of the nurse in supportive care and Prof Lawrence Einhorn: Controversies in management of chemotherapy-induced nausea and vomiting.
The SCILS workshops focused on Breathlessness and persistent cough, Anxiety and Depression, Clots and novel anticoagulants and Oral health, mucositis and osteonecrosis of the jaw. Overall the workshop provided a great opportunity for networking and updating one’s skills and knowledge in the area of advanced practice nursing.
Prof Larry Einhorn presented ‘Nausea is the New Black’. Prof Einhorn proposed that in 2016, nausea not vomiting is the main element of toxicity for Chemotherapy Induced Nausea and Vomiting (CINV) and that Olanzapine, an anti-psychotic, may be the most promising drug for mitigating nausea. Indeed in 1974 when Prof Einhorn began using Cisplatin chemotherapy in testicular cancer patients they could experience up to 10 episodes of emesis a day and now the number is closer to zero.
Karen Mustian, an exercise physiologist and researcher spoke about the optimal dose of exercise for cancer related fatigue. She advised health care professionals (HCP’s) need to become aware of our patients limitations and as such exercise should be individually tailored. Karen emphasized that the bottom line is to avoid inactivity by starting slow and increase both intensity and duration of physical activity. Exercise interventions, it seems, are better than pharmaceuticals at reducing cancer related fatigue.
There were many other presentations that used improving patient engagement and partnering with others eg. Pharma, NGO’s and other HCP’s to meet the supportive care needs of our patients. As clinicians we must be better at toxicity management as reported by patients, including managing both the physical and psychosocial burden these toxicities cause.
The MASCC guidelines and assessment tools can be found on their website at www.mascc.org
Author: Annda Lum
Affiliations: Pamela Youde Nethersole Eastern Hospital, Hong Kong
[Special acknowledgement to Dr Kwok Sing Ng, CP Mr Victor Kong, SWA Ms Christy Lee]
Ms X was a 50 years old lady having hormonal-responsive, HER-2 positive breast cancer with multiple metastases in Feb 2013. She was initially managed in Hospital A, with chemotherapy and radiotherapy given, later defaulted follow-up. Afterwards, she had started to receive Tamoxifen and Herceptin since Mar 2014 in our Unit, eventually passed away in Dec 2015.
Characteristic Exceptions Demonstrated by Ms X
Throughout her treatment process, she demonstrated several characteristic exceptions.
Exceptional keen for hospitalization- prolonged stay in our Orthopedic unit for 537 days and 215 days in our unit without clinical indication.
Exceptional plan for hospitalization- after discharge from Hospital A, Ms X went to different hospitals and requested admissions.
Exceptionally being refused- because of Ms X’s violent behavior, several hospitals marked ALERT not to admit her.
Exceptional treatment refusal- Ms X refused most management as planned for her.
Exceptionally irritable- she attacked staff and generated ward conflicts multiple times. She was diagnosed having adjustment disorder, delusion disorder and personality difficulties.
Family Background and Psychosocial Formulation
Ms X had no contact with family after quarrel at her adolescence. She was an ex-jewelry saleslady. Lived alone in a public housing unit and a Comprehensive Social Security Assistance (CSSA) recipient. Ms X was discriminated by her neighbors too. After onset of her illness, she refused home. Ms X was defensive and hostile towards hospital staff. Nevertheless, she was nice and helpful towards other patients. For instance, she shared pizza with other patients in ward and assisted daily task of another elder in ward.
Ms X was referred to clinical psychologist for illness coping. Rapport building turned out to be a challenging task, as she appeared interpreting any assessment as an attempt to label her as mentally ill. Due to Ms X’s defensiveness and downhill physical condition, intensive psychotherapy targeting delusional beliefs or personality issues was not a realistic option. Instead, psychological intervention focused on providing emotional support and problem solving on her immediate concerns. Efforts were made to facilitate insight regarding how her cognitions affected emotions and medical treatment.
Last Journey and Team Reflection
When Ms X was very weak, she still did not disclose any after-death business. Our team paid much effort to find if Ms X had self-arranged her funeral matter before. Multiple NGOs were contacted and ultimately our social worker was able to identify one to address Ms X’s final need. During the last moments of Ms X, chaplain was invited to see her, our staff and social worker accompanied her at bedside. Conveyable comforts words like “let go” through her ears were done to enhance her spiritual peace. Ms X’s last wish of funeral concern was addressed and fulfilled at her final moment. She rested in peace without lingering time.
Even though Ms X was an exceptional challenging patient to care, we still tried our best to preserve her dignity and the humanity. Our team awareness was increased after debriefing was done regarding to our own emotions and feeling towards Ms X’s care. Mutual staff support with good team spirit was vital for this kind of challenge.
Author: Choy Yin Ping, NC (ONC), KWC
Affiliations: Nurse Consultant., Princess Margaret Hospital, Hong Kong
去年，我有幸代表我的團隊到首爾參加第二屆亞洲腫瘤科護理會議（AONS 2015 Conference），發表了有關跨專業團隊合作診治新服務模式的學術報告。很高興這份報告被大會評審為大會最佳報告之一。
Authors: Matthew Fowler, RN, B (Nurs) PGDip
Affiliations: Heart of England NHS Foundation Trust
This piece of work is adapted from an original article submitted by Matthew Fowler as follows:
Fowler, M., (2015) Management of Patients with Low-Risk Febrile Neutropenia. Cancer Nursing Practice, 14, (5), pp16-21.
Anti-cancer chemotherapy is well documented to cause a plethora of toxicities, however by far one of the most serious complications is that of febrile neutropenia (Innes et al 2003). As a practising ANP (Advanced Nurse Practitioner) for oncology and haematology I am frequently involved with the care and management of patients presenting with febrile neutropenia and was curious as to if length of stay could be reduced for this group of patients.
The NICE guidelines (2012) advocate that patients classified as Low Risk Febrile Neutropenia (LRFN) should be considered for management in the community setting and the tool most widely utilised to identify LRFN patients is the Multinational Association of Supportive Care of Cancer (MASCC) Risk Index which was devised by Klastersky et al (2000) and is demonstrated in Table 1 below
Teuffel et al (2010) have also identified a cohort of patients identified as LRFN in accordance with the MASCC risk index who unfortunately go on to develop complications necessitating hospital admission; this further substantiates the case for initial admission to hospital for a period of observation for LRFN patients. In response to some of the concerns raised about the MASCC risk index, Carmona-Bayonas et al (2011) devised the CISNE (Clinical Index of Stable Febrile Neutropenia) (see Table 2) tool to identify patients who are at low risk of developing complications of FN who can be discharged home after 24 hours if their CISNE score is 0.
Table 2 CISNE tool (Carmona-Bayonas et al 2011)
|Performance Status >2
|Stress Induced Hyperglycaemia
|Chronic cardiovascular disease
|Mucositis grade >2
Use of the CISNE tool has the potential to revolutionise the way in which patients with LRFN are cared for. There is potential for patients with LRFN to be discharged home after 24 hours with oral antibiotics and robust patient education. In my own area of practice, I am in the process of working with the consultant microbiologists, general physicians and oncologists to devise a robust pathway for early discharge of patients with LRFN using the CISNE tool.
This clearly has fundamental and far-reaching implications for both the healthcare economy and most importantly the cancer patient journey. This is the beginning of an exciting development and it is proposed that once this change in practice is embedded that we can begin researching a truly ambulatory model for management of patients with LRFN.
Carmona-Bayonas, A., Gomez, J., Gonzalez-Billalabeitia, E., Canteras, M., Navarrete, A., Gonzalvez, M. L., Vicente, V. and Ayala de la Pena, F. (2011) Prognostic evaluation of febrile neutropenia in apparently stable adult cancer patients. British Journal of Cancer, 105 (5): 612-617.
Innes, H.E., Smith, D.B., O’Reilly, S.M., Clark, P.I., Kelly, V. & Marshall, E. (2003) Oral antibiotics with early hospital discharge compared with in-patient intravenous antibiotics for low-risk febrile neutropenia in patients with cancer: a prospective randomised controlled single centre study. British Journal of Cancer, 89 (1): 43-49.
Klastersky, J., Paesmans, M., Rubenstein, E. B., Boyer, M., Elting, L., Feld, R., Gallagher, J., Herrstedt, J., Rapoport, B., Rolston, K., and Talcott, J. (2000) The Multinational Association for Supportive Care in Cancer Risk Index: A Multinational Scoring System for Identifying Low-Risk Febrile Neutropenic Cancer Patients. Journal of Clinical Oncology, 18 (16): 3038-3051.
National Institute for Health and Care Excellence (2012) Neutropenic Sepsis: prevention and management of neutropenic sepsis in cancer patients (CG51) London: National Institute for Health and Care Excellence.
Teuffel, O., Amir, E., Sung, L. & Alibhai, S. M. (2010) Treatment strategies for low-risk febrile neutropenia in adult cancer patients: A cost-utility analysis. (2010) Journal of Clinical Oncology, 28:15s, (suppl; abstr 6102)