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MARCH 2017 www.TheOncologyNurse.com VOL 10, NO 2

CANCER CENTER PROFILE Direct Access to Colonoscopy Massachusetts General Hospital Improves Screening Rates, Cancer Center: Survivorship Adenoma Detection Initiative for Patients Who Have By Wayne Kuznar

Undergone Bone Marrow Transplant San Francisco, CA—A Direct Access ity for the program and provides in- Screening Colonoscopy (DASC) pro- structions for bowel preparations, said gram at Advocate Illinois Masonic Gabriel Rodriguez, MD, resident, Ad- Medical Center in Chicago was found vocate Illinois Masonic Medical Cen- to increase the overall screening rate for ter, at the 2017 Gastrointestinal Can- colorectal cancer (CRC) by almost cers Symposium. 100% without excess complications. CRC is a highly preventable disease if The program is run by a nurse naviga- detected early. Despite efforts to inform tor, who questions patients over the the public about the clear benefit of telephone to determine patient eligibil- CRC screening, the majority of the pop- CommunicationsContinued on page 8

The Mass General Bone Marrow Transplant Survivorship Program team (left to right): Areej El-Jawahri, MD; Julie Vanderklish, NP. Autologous Breast Reconstruction Has Better he Mass General Cancer Center is an integral part of a top-flight academ- ic medical center: Massachusetts General Hospital. The Mass General Outcomes Than Implants in TCancer Center is among the leading cancer care providers in the United States, and is a National Cancer Institute–designated comprehensive cancer Patients Receiving Radiotherapy center as part of the 7-member Harvard Medical School consortium. This con- Continued on page 7 By Phoebe Starr

San Antonio, TX—The largest study to “The benefits of radiation for selected Reducing Disparities in date comparing outcomes of radiation women with breast cancer are well- therapy and postmastectomy breast re- established. Updated guidelines recom- Survivorship Care Healthcareconstruction found higher rates of com- mend individual consultations for plication and failure in women who women who want breast reconstruction. By Chase Doyle received radiation therapy and had im- Breast reconstruction has a significant plant reconstruction versus autologous impact on survivors. The integration of San Diego, CA—Surviving cancer is cancer and its treatment; concerns re- reconstruction. These data have been radiation and reconstruction is widely the start of a new journey for many in- Hilllated to employment, insurance, and long-awaited, because there are no firm feared and poorly understood, with only dividuals. Cancer survivors face a mul- disability; and coordination between guidelines, and more women are being limited evidence to date,” said Reshma titude of challenges, including preven- specialists and primary care providers. treated with radiotherapy. Jagsi, MD, DPhil, Deputy Chair, Depart- tion of new and recurrent cancers; These challenges are compounded Continued on page 18 interventions for illnesses secondary to when trying to ensure the appropriate, INSIDE Continued on page 12 8 Colorectal Cancer 16 Lung Cancer Daily moderate exercise can improve Managing immune-related toxicities in outcomes in patients with metastatic patients with lung cancer Green colorectal cancer 18 Breast Cancer 10 Genetic Counseling Specific menopausal symptoms New data suggest the benefit of associated with nonadherence to © multigene panel testing for patients hormonal therapy in women at risk with early-onset colorectal cancer for breast cancer

13 Survivorship 22 Pancreatic Cancer Internet-generated survivorship Duloxetine improves chemotherapy- care plans are convenient and induced peripheral neuropathy in customized patients with pancreatic cancer

Survivorship Initiative for Patients... Continued from the cover sortium forms the largest research col- TON: What does the initial laborative in the country, and has par- assessment entail? ticipated in developing promising new Ms Vanderklish: It takes approximately treatments that have revolutionized the 4 hours to complete a survivorship con- treatment of cancer. sult. We approach a survivorship visit by The Mass General Cancer Center first reviewing the patient’s diagnosis, provides customized multidisciplinary cancer treatment (including BMT), side care to children and adults. In addition effects, and medical history. Next, Dr to medical oncology, surgical oncology, El-Jawahri or myself meet with the pa- and radiation oncology, the cancer cen- tient, which takes approximately 60 to ter offers a full range of cancer care– 90 minutes. After that, we write an indi- related programs. vidualized survivorship care plan in the These include the Katherine A. Gal- longitudinal medical record and discov- lagher Integrative Therapies Program, er our recommendations with the BMT which offers free wellness programs for team, primary care physician, and the patients and their caregivers; the Life- Julie Vanderklish, NP Areej El-Jawahri, MD patient. This takes approximately 4 to 5 style Medicine Clinic for patients and hours. Our patients also meet with the survivors who want a personalized con- Our goals are to als, and methods for communicating social worker for 1 hour to process the sultation to improve their overall phys- with BMT specialists, primary care BMT experience, and with a program ical fitness and quality of life; a sexual provide high-quality physicians, and patients. We worked nurse to review things such as diet, exer- health clinic; the Marjorie E. Korff survivorship care, with excellent social workers and psy- cise, infection prevention, and educa- PACT program, which offers psychoed- chologists in developing the psychoso- tion about chronic GVHD. ucational support for patients who are conduct innovative cial component of our program and parents; and the Center for Psychiatric support services. TON: How did your career Oncology and Behavioral Sciences, research specific to path lead to caring for which helps patients cope with the psy- BMT survivorship, and TON: This soundsCommunications like a time- patients who have had BMT? chological and behavioral impact of consuming effort. Ms Vanderklish: During nursing their cancer. improve the quality of Ms Vanderklish: Yes, it took us more school at Northeastern University, Bos- The Mass General Bone Marrow life and care of BMT than 1 year, working part-time approxi- ton, MA, one of my cooperative work/ Transplant (BMT) Survivorship Pro- mately 10 to 20 hours per week, to de- study programs was at Dana-Farber gram is a new initiative specifically de- survivors, their families, sign the program. Cancer Institute, Boston, in the BMT signed to improve the lives of patients inpatient unit. I fell in love with trans- who have undergone BMT. The pro- and caregivers. TON: Did you and Dr plant and the patients I met there. gram features several unique compo- —Julie Vanderklish, NP El-Jawahri have any help in Since then, except for a brief hiatus nents that address the various aspects of laying the groundwork? to have my children, I have always BMT survivorship, and is open to pa- cialists, medical experts, palliative care, Ms Vanderklish: Dr El-Jawahri and I worked with BMT patients. After tients who are ≥1 years post-BMT. and support for sexual health and psy- did most of the groundwork. However, working at Massachusetts General Hos- The Oncology Nurse-APN/PA (TON) chosocial issues. we received guidance and support from pital on the inpatient BMT floor, I spoke with Julie Vanderklish, NP, about many local experts in BMT and chron- wanted to be able to expand my role in the comprehensive efforts involved in TON: How did you go about ic graft-versus-host disease (GVHD), transplant. So I went back to school to planning the program and bringing it to designing the program? such as Nathaniel Treister, DMD, become a nurse practitioner. I have fruition. Ms Vanderklish is co-leader of Ms Vanderklish:Healthcare We realized we first DMSc, Chief, Division of Oral Medi- been a nurse practitioner for 17 years the program under the directorship of needed to understand survivorship and cine and Dentistry, Brigham and Wom- within the Partners System at Massa- Areej El-Jawahri, MD, a BMT and pal- what it entails. We reviewed data on en’s Hospital, Boston, MA; Arturo P. chusetts General Hospital, Dana-Far- liative care specialist at the Mass Gen- the effects of cancer treatments and Saaverdra, MD, PhD, Medical Direc- ber Cancer Institute, and New- eral Cancer Center. BMT complications, as well as survivor- tor, Medical Dermatology, Massachu- ton-Wellesley Hospital. My main area shipHill recommendations from the Ameri- setts General Hospital; and many oth- of interest is chronic GVHD, a com- TON: What distinguishes the can Cancer Society, the American ers. Our superb social work, psychology, plex side effect of BMT that has a sig- BMT Survivorship Program Society of Clinical Oncology, the Na- nursing, and nurse practitioner teams nificant impact on quality of life. from other survivorship tional Institutes of Health, and the Na- were also very helpful. programs? tional Cancer Institute. We also met We performed a trial run that started TON: Have there been any Julie Vanderklish: As far as I am with directors of other BMT survivor- in July 2016. We saw 23 patients recent advances in the aware, there is a limited number of ship programs and then began our clin- through December and then reviewed management of chronic BMT survivorship programs in the ical design. our approach and made some adjust- GVHD? United States. We designed our pro- We created up-to-date follow-up ments. We officially opened on January Ms Vanderklish: We are getting better gram based on Greenthe recognition of the recommendations for each organ sys- 6, 2017, and are seeing 1 to 2 patients at preventing GVHD using targeted immense medical, psychological, and tem affected by BMT. We collaborat- weekly. To date, 30 patients have been therapies, whereas in the past we relied survivorship needs of hematopoietic ed with Massachusetts General Hospi- through our survivorship program. Our more on high-dose steroids. We now stem-cell© transplant recipients. Our tal staff who were experts in each of goal is that every patient who has un- have specialists who focus on various goals are to provide high-quality survi- those areas and who had clinical inter- dergone an allogeneic stem-cell trans- organ systems affected by GVHD, and vorship care, conduct innovative re- est in the long-term complications of plant at Massachusetts General Hospi- are able to tailor our treatments accord- search specific to BMT survivorship, BMT. We also made sure that these tal will be seen at the clinic. People ingly. Compared with 17 years ago, pa- and improve the quality of life and care experts would be available for quick who are ≥12 months from time of tients now have new treatment options of BMT survivors, their families, and referral. Finally, we were able to de- transplantation can be referred. We depending on the site of chronic caregivers. sign the clinic operations, the survi- now have approximately 60 referrals GVHD (ie, oral, ocular, genital, and Our program incorporates BMT spe- vorship care plan, educational materi- awaiting consult. skin/fascia). Continued on page 9 www.TheOncologyNurse.com MARCH 2017 I VOL 10, NO 2 7 COLORECTAL CANCER Evidence Supports the Use of Aspirin for Precision Chemoprevention of Colorectal Cancer By Meg Barbor, MPH

Cape Town, South Africa—Over- cancer, and less successful in reducing and mortality from, CRC with regular preventive medicine. With the excep- whelming evidence supports a chemo- the risk of proximal colon cancer. So aspirin use. In 8 cardiovascular RCTs, tion of tamoxifen for women at high preventive benefit of aspirin on colo there’s reason to consider other types of aspirin reduced the risk for overall can- risk for breast cancer, this is the first rectal cancer (CRC), and a potential modalities, particularly modalities that cer death. medication broadly recommended for effect on other cancers and cardiovas- are more cost-efficient,” Dr Chan said. “Cancer is poised to overtake cardio- cancer prevention by the USPSTF,” cular risk, according to Andrew T. said Dr Chan. Chan, MD, MPH, Chief, Clinical and Translational Epidemiology Unit, and “Cancer is poised to overtake Personalizing Director, Gastroenterology Training Chemoprevention Program, Massachusetts General Hos- cardiovascular disease as the Despite increased recognition of the pital, Boston, at the American Associ- leading cause of death in the effectiveness of aspirin as chemopreven- ation for Cancer Research Interna- tion, wider-scale efforts are limited be- tional Conference on New Frontiers in US [United States], so aspirin cause of concerns over its established Cancer Research. can potentially have an impact association with gastrointestinal bleed- “Aspirin is potentially the chemo- ing. The hazards associated with long- preventive agent for which there is the on the 2 leading causes of term aspirin use do necessitate strategies strongest evidence of effectiveness at for risk prevention, cautioned Dr Chan. prevention,” he said. mortality in much of the world.” He said molecular and genetic mark- Consistent experimental and epide- —Andrew T. Chan, MD, MPH ers in prostaglandin and inflammatory miologic evidence has demonstrated an pathways hold particular promise for association between aspirin and a lower precision medicine. As part of a broader risk for CRC. In addition, 5 place- The CAPP2 RCT examined aspirin vascular disease as the leading cause of effort to tailor prevention strategies, Dr bo-controlled, randomized controlled use among patients with the Lynch death in the US [United States], so as- Chan and colleagues have led several trials (RCTs) among patients with a hereditary CRC syndrome, and data pirin can potentiallyCommunications have an impact on studies into the mechanistic basis of history of colorectal adenoma or cancer from long-term follow-up demonstrated the 2 leading causes of mortality in aspirin’s anticancer effect, and, in turn, showed that aspirin reduced the risk for that randomized aspirin treatment was much of the world,” he said. have developed intratumoral, colonic, recurrent adenomas, which are precur- associated with a lower-risk for CRC. In 2016, the US Preventive Services germline, and circulating molecular sors to the vast majority of cancers, re- The same results were demonstrated in Task Force (USPSTF) updated its pri- correlates of outcomes. ported Dr Chan. the Women’s Health Study, an RCT mary prevention guidelines for aspirin “Such biomarkers can be exploited that examined the effectiveness of aspi- because of overwhelming evidence in for risk stratification to more effectively Aspirin’s Impact rin for the primary prevention of can- support of its benefits. The USPSTF target aspirin chemoprevention for Other modalities of CRC prevention cer and cardiovascular disease. now recommends low-dose aspirin (81 those with more favorable risk-benefit rely heavily on screening—in particu- “It’s very well-known that aspirin mg daily) for the primary prevention profiles,” he said. lar, colonoscopy screening. Although potentially has benefits for the preven- for cardiovascular disease and CRC in “Aspirin can impact multiple steps in there is widespread consensus that this tion of cardiovascular disease,” Dr adults aged 50 to 59 years, and possibly the pathway, so you can imagine the type of screening is effective, certain Chan noted. Secondary analyses of aged 60 to 69 years, with a >10% 10- potential. Even if patients develop re- limitations exist. RCTs of aspirin for the prevention of year risk for cardiovascular events. sistance to 1 pathway, they can still be “It appears to be more successful in cardiovascular disease have demon- “This recommendation represents a sensitive to aspirin because it can affect reducing the risk of distal colorectal strated reductionsHealthcare in the incidence of, significant milestone for the field of other pathways,” Dr Chan added. n

Massachusetts HillGeneral Hospital Cancer Center... Continued from page 7 TON: How did you get on March 1, 2017, that will deliver 8 time, not overwhelm them with multi- specific component of our survivorship involved in the survivorship weekly sessions, each 1.5 hours in ple follow-up appointments and testing. program, but a very important one. program? length, covering different long-term Ms Vanderklish: I met Dr El-Jawahri at complications of BMT. These include TON: What aspect of this TON: Do you plan to quantify Massachusetts General Hospital and she intimacy and communication effects, work is the most rewarding? your results? knew about my BMT experience and chronic GVHD, and fatigue. Each ses- Ms Vanderklish: By educating our pa- Ms Vanderklish: We will use specific in-depth interest in chronic GVHD. sion is co-led by a nurse practitioner or tients and other physicians about BMT quality metrics, including bone health, She asked if I would be interested in physician and a psychologist, and the survivorship, our patients will have pulmonary function tests, ocular exams, developing a survivorshipGreen program. focus is on education, discussion, and better clinical outcomes and improved and other measures for the different mindfulness exercises. quality of life. This is the most exciting organ systems. TON: Can you provide and rewarding aspect of this initiative. some© specific examples of TON: What is the most For example, I’ve seen patients who TON: Is the survivorship interventions you will use in challenging aspect of have not been able to have sexual in- program covered by health the BMT Survivorship working with BMT survivors? tercourse for years because of pain relat- insurance? Program? Ms Vanderklish: The biggest challenge ed to GVHD or vaginal atrophy. We Ms Vanderklish: I have had no issues Ms Vanderklish: We are preparing to is time management. Many patients have been able to offer interventions to regarding coverage for a survivorship initiate patient and caregiver support have multiple problems that are clini- alleviate these symptoms and improve visit. Survivorship consultations will groups and patient support groups. In cally complex. We have to address all of or restore their sexual health. become standard for BMT programs addition, we plan to launch a webinar their healthcare needs, and, at the same Addressing sexual health is only one around the country. n