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November is Pancreatic Cancer Awareness Month

November 4th, 2019 in Hot Topics, International News, Reflection

Submitted by Fedricker D. Barber, PhD, ANP-BC, AOCNP, University of Texas MD Anderson Cancer Center, Houston, TX

Did you know that November is Pancreatic Cancer Awareness Month and that November 21, 2019 is World Pancreatic Cancer Day? Pancreatic cancer is one of the deadliest cancers worldwide and is one of the leading causes of cancer mortality in developing countries (World Health Organization, n.d.). In 2018, approximately 458,000 people were diagnosed with pancreatic cancer, and an estimated 456,280 people are expected to die from this disease by 2020 (World Health Organization, n.d.). Currently, there is no cure for pancreatic cancer and there are no screening tests to detect this disease, therefore, education and awareness are key to preventing pancreatic cancer.

Incidence

The incidence rate for pancreatic cancer varies, for example, the highest incidence rate was in North America (50,745) and Europe (128,045) in 2018 (World Health Organization, n.d.). Whereas, the lowest incidence rate was in Africa (15.458) in 2018 (World Health Organization, n.d.). Generally, pancreatic cancer is more prevalent in men than in women and is a disease of older adults, with a median age of onset of 71 years (Ilic & Ilic, 2016; McGuigan et al., 2018; McWilliams et al., 2016).

Risk Factors

Researchers are making progress in understanding the causes of pancreatic cancer, however, the precise cause is unknown. Epidemiological data suggests that family history of pancreatic cancer, smoking, obesity, diabetes mellitus, and chronic pancreatitis are associated with pancreatic cancer (Ilic & Ilic, 2016; McWilliams et al., 2016). Additionally, alcohol use > 26 grams daily has been identified as a risk for pancreatic cancer (Ilic & Ilic, 2016; McWilliams et al., 2016).

Clinical Manifestations

Unfortunately, clinical manifestations of pancreatic cancer usually do not occur until the cancer has invaded other organs (McGuigan et al., 2018). Common symptoms include: unexplained weight loss, epigastric pain that radiates to the back, jaundice, anorexia, abdominal bloating, clay-colored stools, nausea, and fatigue (McGuigan et al., 2018).

Survival

The major factor impacting survival and outcomes in patients with pancreatic cancer is the tumor stage. For instance, the 5-year survival rate for patients with pancreatic cancer is 6% worldwide, however, with localized disease, the 5-year survival rate is 37% versus 3% for stage IV disease (McGuigan et al., 2018).

Treatment

Treatment for pancreatic cancer varies depending on the stage of the disease. Surgical resection such as pancreatico-duodenectomy or total pancreatectomy potentially can cure pancreatic cancer (McGuigan et al., 2018). Other treatment options such as chemotherapy and chemo-radiotherapy have been showed to increase overall survival (71%-76%), however, patients tend to have recurrent disease within two years (McGuigan et al., 2018).

Conclusion

Given that there is no reliable screening test available to detect pancreatic cancer, education and awareness is key to prevention and early diagnosis.

References

Ilic, M., & Ilic, I. (2016). Epidemiology of pancreatic cancer. World J Gastroenterol, 22(44), 9694-9705. doi:10.3748/wjg.v22.i44.9694

McGuigan, A., Kelly, P., Turkington, R. C., Jones, C., Coleman, H. G., & McCain, R. S. (2018). Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol, 24(43), 4846-4861. doi:10.3748/wjg.v24.i43.4846

McWilliams, R. R., Maisonneuve, P., Bamlet, W. R., Petersen, G. M., Li, D., Risch, H. A., . . . Lowenfels, A. B. (2016). Risk Factors for Early-Onset and Very-Early-Onset Pancreatic Adenocarcinoma: A Pancreatic Cancer Case-Control Consortium (PanC4) Analysis. Pancreas, 45(2), 311-316. doi:10.1097/mpa.0000000000000392

World Health Organization. Cancer tomorrow. (n.d). Retrieved from http://gco.iarc.fr/

Mindfulness-Based Interventions in Cancer Care

October 11th, 2019 in Editorial Office, Reflection

Written by:
Karen Kane McDonnell, PhD, RN, Associate Professor David G. Gallerani, MPH, Research Associate Amanda R. Myhren-Bennett, MSN, RN, PhD student
Lung Cancer Survivorship Research Program, College of Nursing, University of South Carolina, Columbia, SC, USA

Mindfulness is derived from Buddhist traditions and described by one author as an intentional and nonjudgmental awareness of the present moment (Kabat-Zinn, 1990). Mindfulness-based interventions (MBIs) are used to treat and prevent a wide range of chronic conditions.

Mindfulness-Based Stress Reduction (MBSR)—a group-based, eight-week program and one of the most well-known MBIs—was developed by Jon Kabat-Zinn, PhD, currently founding executive director of the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School in the United States and its renowned Stress Reduction Clinic.

Mindfulness specifically helps survivors of cancer, their family members, and/or friends cope with symptoms of cancer, cancer therapies, and related stress (Rouleau, Garland, & Carlson, 2015). Dubbed a “healing practice” by Carlson and Speca (2010), mindfulness may even enhance immune system performance and reduce harmful levels of circulating stress hormones.

The Foundation: MBCR

Mindfulness-Based Cancer Recovery (MBCR) is one of many interventions built on MBSR (Carlson & Speca, 2010). At each session, participants engage in mindfulness practices, including gentle yoga and meditations. By repeatedly returning their attention to current experiences, participants gradually learn to disengage from dysfunctional thoughts and experience the emotions and bodily sensations of the present moment. Like MBSR, MBCR teaches participants to stop worrying or ruminating about the past and the future and to simply allow life experiences to unfold.

Mindfulness-Based Cancer Recovery (MBCR) is one of many interventions built on MBSR (Carlson & Speca, 2010). At each session, participants engage in mindfulness practices, including gentle yoga and meditations. By repeatedly returning their attention to current experiences, participants gradually learn to disengage from dysfunctional thoughts and experience the emotions and bodily sensations of the present moment. Like MBSR, MBCR teaches participants to stop worrying or ruminating about the past and the future and to simply allow life experiences to unfold.

Randomized clinical trials involving MBSR, MBCR, and other MBIs have shown efficacy in patients with cancer—that is, they have yielded improved psychosocial and physical outcomes (Carlson, 2017; Johannsen et al., 2016; Lengacher et al., 2016; Zhang et al., 2015). Yet, very few studies have involved survivors of early-stage non-small-cell lung cancer (NSCLC). With consultation from Linda Carlson, Enbridge Research Chair in Psychosocial Oncology at the University of Calgary and co-founder of the Tom Baker Cancer Centre’s MBCR program, a team of researchers, clinicians, and mindfulness practitioners adapted MBCR for this specific population of survivors of lung cancer and family members (dyads).

Breathe Easier

In 2017–18, the adapted program, Breathe Easier, was pilot tested using a prospective, one-group, repeated measure, mixed-method design, for feasibility (recruitment, retention, adherence, acceptability) and preliminary effects (symptom improvement—of dyspnea, fatigue, stress, and insomnia).

The following instruments measured outcome variables (see footnote 1):

• FACIT Dyspnea Short Forms
• FACIT Fatigue Scale v. 4
• Perceived Stress Scale v. 4
• Pittsburgh Sleep Quality Index

Using Stata v. 14, descriptive statistics were obtained for feasibility measures. Student t-tests were performed for subset comparisons. Face-to-face interviews (all audio-recorded and transcribed) extracted dyads’ perceptions. NVivo Pro 12 was used for data management, and thematic analysis was used for data analysis.

Results

The greatest challenge was recruitment. This and other facts about the sample follow:

  • 20% recruitment (31 dyads or 62 participants of 164 survivors reached)
  • 94% retention
  • 62% African American
  • 44% male

Adherence was demonstrated by good attendance and exceeding expectations on home assignments (breathing exercises and meditations). All participants practiced gentle movements (sitting, standing, and floor yoga) and met about 80% of expectations.

All agreed the intervention materials were easy to use, that learning yoga and breathing exercises helped them, and that involving a family member was important. Survivors had less dyspnea and less perceived stress over time. Fatigue and sleep scores improved for both survivors and family members. Six themes emerged from interview data and enriched our understanding of feasibility and preliminary outcomes:

  1. Learning to Breathe Easier
  2. Interacting with Others Benefits Me
  3. Stretching, Releasing Tension, and Feeling Energized
  4. Enhanced Closeness with Committed Partners
  5. Refocusing on Living
  6. Sustaining New Skills Is a Decision

Conclusions

The pilot test’s strong retention, adherence, and acceptability demonstrate strong feasibility overall. Slow recruitment may be attributable to the isolating nature of lung cancer, uniqueness of the intervention, relatively low volume of early-stage survivors, and/or requirement of a family member to take part.

Preliminary outcome data indicate benefits of Breathe Easier over time for both survivors of NSCLC and their family members. Intervention development team members were inspired by participants’ engagement and are seeking funding to implement the next steps.

References:

Carlson, L. E. (2017). Mindfulness and cancer care: Easing emotional and physical suffering. Alternative and Complementary Therapies, 23(5), 167–170.

Carlson, L., & Speca, M. (2010). Mindfulness-based cancer recovery: A step-by-step MBSR approach to help you cope with treatment and reclaim your life. Oakland, CA: New Harbinger Publications.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. New York, NY: Delacourt.

Lengacher, C. A., Reich, R. R., Paterson, C. L., Ramesar, S., Park, J. Y., Alinat, C., … Jacobsen, P. B. (2016). Examination of broad symptom improvement resulting from mindfulness-based stress reduction in breast cancer survivors: A randomized controlled trial. Journal of Clinical Oncology, 34(24), 2827.

Johannsen, M., O’Connor, M., O’Toole, M. S., Jensen, A. B., Højris, I., & Zachariae, R. (2016). Efficacy of mindfulness-based cognitive therapy on late post-treatment pain in women treated for primary breast cancer: A randomized controlled trial. Journal of Clinical Oncology, 34(28), 3390-3399.

Rouleau, C. R., Garland, S. N., & Carlson, L. E. (2015). The impact of mindfulness-based interventions on symptom burden, positive psychological outcomes, and biomarkers in cancer patients. Cancer Management and Research, 7, 121.

Zhang, M., Wen, Y., Liu, W., Peng, L., Wu, X., & Liu, Q. (2015). Effectiveness of mindfulness-based therapy for reducing anxiety and depression in patients with cancer: A meta-analysis. Medicine, 94(45), 1–9.


Footnotes (1) References for instruments: Carpenter, J. S., & Andrykowski, M. A. (1998). Psychometric evaluation of the Pittsburgh sleep quality index. Journal of Psychosomatic Research, 45(1), 5–13; Choi, S. W., Victorson, D. E., Yount, S., Anton, S., & Cella, D. (2011). Development of a conceptual framework and calibrated item banks to measure patient-reported dyspnea severity and related functional limitations. Value in Health, 14(2), 291-306.Roberti, J. W., Harrington, L. N., & Storch, E. A. (2006). Further psychometric support for the 10‐item version of the perceived stress scale. Journal of College Counseling, 9(2), 135-147. Webster, K., Cella, D., & Yost, K. (2003). The functional assessment of chronic illness therapy (FACIT) measurement system: properties, applications and interpretation. Health and Quality of Life Outcomes, 1(79), 1-7.

Sharing on Lymphodema training 淋巴水腫之學習篇

December 22nd, 2016 in Reflection

Author: Lam Choi Hung, Carol

Affiliations: Breast Cancer Case Manager, Pamela Youde Nethersole Eastern Hospital, Hong Kong

曾經是外科乳科護士的我,現為腫瘤科乳癌個案護士,一直抱著學海無涯的心態,希望通過不斷學習和實踐,盡力理解乳癌病人的身心需要,努力為病者及其身邊人提供更為適切的護理和照顧 。

 

乳癌病者從確診、手術、輔助治療、以至步入康復階段,心情上不免經歷高低起伏,照顧上更有着不同的需要。身為護理專業的我們有着重要的角色去盡力明白、理解、協助並與病者同心同行去面對疾病及接受治療。

 

大部分乳癌病者都會有擔憂或面對淋巴水腫的困擾,其普遍性及對病者的影響正是我期望有機會可以深入學習和鑽硏的護理課題。

 

淋巴水腫主要是由於手術及電療所引發的後遺症,可於治療或康復階段發生。雖然現今的前哨淋巴切除技術已經大大減少了淋巴水腫的出現,但病者擔憂受其影響的情緒卻沒有因此而減少 。護士在處理淋巴水腫的角色上,主要是教育、評估、輔導及轉介為主,包括:向病者講解淋巴水腫的成因;教授如何調整在生活細節中的護理以減低水腫出現的機會;提供適切和及時的評估;以及轉介病者進行相關的物理或職業治療。

 

今年二月承蒙部門主管及同事的支持,讓我有機會遠赴澳洲坎培拉由淺入深學習處理淋巴水腫。課程為期三週,除了學習基本的病理成因,此行最重要的目標是學習淋巴水腫治療方法及技巧。

 

我們的學習小組共有14人,學員當中有五位是護士、兩位物理治療師、其餘的都是按摩治療師。在澳洲當地,對淋巴水腫護理的服務需求與日俱增,已經不是醫院可以單方面能應付得來,由社區護理服務給病者提供支援的模式遂應運而生。如何可以在醫院平台提供改善病人這方面的護理需要,這正是作為護士及有關機構值得深思的問題!

 

在三週的學習過程,與來自不同專業背景的海外同學一起集思互動,讓我獲益良多,大家的目標都是希望為淋巴水腫患者提供最為合宜的護理照顧。要成為一位合資格的淋巴水腫治療師,當然要過五關斬六將的完成評核及考試。有志者事竟成,我終於不負眾望取得了澳洲當地的認可治療師資格。

 

回到工作崗位,我一直思索如何學以致用幫助病人施行人手淋巴引流按摩治療,由於醫院實際工作安排真的不容抽身,要把這個想法付諸實行絕對是一個挑戰。 最後唯有嘗試簡化整套人手淋巴引流按摩治療法,以教導病者自己在家施行。意想不到的是,教導了五位有初期淋巴水腫徵狀的病者後,當中有四位都興奮地回覆這簡化版淋巴引流按摩有著明顯的紓緩果效,這鼓舞了我繼續思考如何在醫院平台上多走一步,在病者等候轉介的期間可推廣有關淋巴引流按摩。雖然仍有許多不足及有待改善之處,但初步成績已大大加強了自己的信心,並進一步滿足病者的護理需要。

 

practical-assessment

Practical Assessment

The 25th Multinational Association of Supportive Care in Cancer (MASCC) Meeting

August 11th, 2016 in Reflection

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

A Case Sharing- An Exceptional Challenging Cancer Patient

July 14th, 2016 in Reflection

Annda LumAuthor: 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]

Case Background

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.