EDUCATION FOR A BETTER CHEMOTHERAPY EXPERIENCE€¦ · van Dulmen S, Driesenaar J, van Weert J, van...

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EDUCATION FOR A BETTER CHEMOTHERAPY EXPERIENCE

Ellen Manzullo, MD, FACP

Professor of Medicine Clinical Deputy Division Head, Internal Medicine

UT MD Anderson Cancer Center

Faculty Disclosure

No, nothing to disclose

SessionOutline

1.  AspectsofEduca0onpriortotheini0a0onofChemotherapy

2.  Thrombosisandeduca0ononit'spreven0onandtreatment

3.  Poten0alsideeffectsofChemotherapy

•  Ques0onsandAnswers

4.  PsychosocialaspectsoftreatmentwithChemotherapy

5.  HealthyLifestylePromo0on

•  Ques0onsandAnswers

ChallengesofPa2entEduca2onPriortoChemotherapy

•  Pa0entsoGenareoverwhelmedwithfacingapoten0allifethreateningillness

•  Many0mescancerpa0entsundergoextensivetreatmentoveraprolonged0mecourse

•  TheshiGinchemotherapytreatmentfromtheinpa0enttooutpa0entseKnghasdecreasedtheamountof0meforpa0enteduca0on

•  Outpa0entchemotherapyhasmadeitimportantforbothpa0entsaswellastheircaregiverstobeknowledgeableaboutsideeffecttreatmentinthehome

ChallengesofPa2entEduca2onPriortoChemotherapy

•  Morethan60%ofallcancerpa0entsare65yearsofageandabove

•  Many0mescancerpa0entsalsohaveamul0tudeofothercomorbidcondi0ons

•  Astudyhasshownthatolderpa0entsonlyac0velyrecalllessthanonefourthoftheeduca0onfocusedonsideeffecttreatmentprecedingchemotherapy

JansenJ,vanWJ,vanderMeulenN,vanDulmenS,HeerenT,BensingJ.(2008).Recallinoldercancerpa0ents:measuringmemoryformedical

informa0on.Gerontologist,48(2);149-157

Pa2entVOICE:AnOnlineCommunica2onToolforOlderPa2entswithCancer

•  Online,preparatorytoolwithaudiofocusedonimprovingthepar0cipa0onofolderpa0ents(65yearsorolder)duringeduca0onalnursingencountersbeforechemotherapyandalsoimprovingtheirinforma0onrecall

•  Pa0entVOICEwasdevelopedwithinvolvementofbothpa0entsandnurses

•  Pa0entVOICEprovidespre-visitinforma0onaboutchemotherapy,thenursingvisit,andtheroleofthepa0entduringtreatment

•  Futureresearchisgoingtobeconductedonit'su0lityandusabilityinagroupofolderpa0entswhoreceiveorhavereceivedchemotherapy

vanDulmenS,DriesenaarJ,vanWeertJ,vanOschM,NoordmanJ.(2017).Pa0entVOICE:DevelopmentofaPreparatory,Pre-ChemotherapyOnline

Communica0onToolforOlderPa0entsWithCancer.JMIRResearchProtocols,6(5),1-11

Evalua2onoftheAddi2onofVideo-basedEduca2onforPa2entsReceivingStandardPre-ChemotherapyEduca2on

•  Aimofthestudywastoevaluatetheusefulnessofaneduca0onalvideowithregardtopa0ents'abilitytorecallandreportsideeffectsoftreatment

•  Pa0entswerethosewithnewlydiagnosedbreastorcolorectalcancer,betweenages18-75,whoweretoreceiveadjuvantchemotherapy

•  Pa0entswererandomizedtoreceivestandardpre-chemotherapyeduca0onorstandardeduca0onplusaddi0onofavideo

•  Thevideo,"StayingWellDuringChemotherapy",focusedonmostcommonsideeffectsoftreatmentwitheduca0onontheirmanagement

Kinnane,N.,&Thompson,L.(2008).Evalua0onoftheaddi0onofvideo-basededuca0onforpa0entsreceivingstandardpre-chemotherapyeduca0on.

EuropeanJournalofCancerCare,17(4),328-339

Evalua2onoftheAddi2onofVideo-basedEduca2onforPa2entsReceivingStandardPre-ChemotherapyEduca2on

HypothesisoftheStudy:•  Pa0entswhowatchedthevideo

inaddi0ontoreceivingwriienandverbalinstruc0onsarebeierabletorecallsideeffectsoftreatmentandwouldperformearlyrepor0ngoftreatmentsideeffects

SpecificAimsoftheStudy:•  Comparerecallofinforma0on

regardingself-careandsideeffectsinpa0entswhowatchedthevideoaspartoftheirpre-chemotherapyeduca0onwiththosewhoreceivedstandardcare.

•  Surveypa0entsandevaluatetheusefulnessofthevideoinassis0ngthemmanagesideeffectsofchemotherapyinthehome.

Pa2entSelec2on

•  Pa0entswithcolorectalcancerandwerescheduledtoreceiveadjuvantchemotherapywithweekly5FluorouracilandFolinicAcid

•  Pa0entswithbreastcancerandwerereceiving5Fluorouracil,EpirubicinandCyclophosphamideorAdriamycin/EpirubicinandCyclophosphamideChemotherapy

•  Pa0entshadEnglishastheirprimarylanguage

•  ECOGscore0-2

ExclusionCriteria

•  Iftheyoranyimmediatefamilymemberhadpriorchemotherapy

•  Comorbidcondi0onthatwouldprohibitcomprehensionandgivinginformedconsent

•  Visuallyorhearingimpaired

•  Unabletocompletetheques0onnaire

WithdrawalCriteria

•  Pa0entswerewithdrawniftheyhadtoxici0esthatrequiredstoppingtreatment

•  Iftreatmenthadtobedeferredduetoseriousillnesslas0ngmorethan3weeks

"StayingWellDuringChemotherapy"includedthefollowing:

•  Selfhelpformul0plesymptoms–  Nausea/vomi0ng–  Infec0on–  Anemia–  Thrombocytopenia–  Mouthcare–  Dietary&fluidintake–  Diarrhea–  Cons0pa0on

•  Pa0entswerealsoinstructedwhentoseekmedicalcare

Kinnane,N.,&Thompson,L.(2008).Evalua0onoftheaddi0onofvideo-based

educa0onforpa0entsreceivingstandardpre-chemotherapyeduca0on.EuropeanJournalofCancerCare,17(4),328-339

"StayingWellDuringChemotherapy"includedthefollowing:

•  Pa0entscompletedabaselineques0onnaireevalua0ngknowledgeandanotherques0onnairepriortothesecondchemotherapycycleevalua0ngrecallofinforma0on

•  Pa0entswhowatchedthevideowereaskedtoassessthevideoaGer6cyclesofchemotherapy

•  Telephonecallstothedepartmentrepor0ngsymptomswereevaluatedforbothgroups

Results

•  Thevideogroupshowedatrendtowardshigherrecallininforma0onpertainingto:

–  Fever–  Mouthproblems–  Anemia–  Preven0onofcons0pa0on

•  Thevideogroupmorecommonlytelephonedrepor0ngmedicalproblemsof:

–  Nausea–  Vomi0ng–  Signsofinfec0oncomparewiththestandardgroup

InternetResourcesforPa2entsonChemotherapy:SideEffects

•  ASCO:hips://www.cancer.net/naviga0ng-cancer-care/side-effects

•  NCI:hips://www.cancer.gov/about-cancer/treatment/side-effects

•  ACS:hips://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects.html

Pa2ent-orientedAPPS

iOS(iPhone/iPad):

CaringBridgeHelpConnectcaregivers&Pa0entswithsupportsystem.Link:hips://itunes.apple.com/us/app/caringbridge/id365726944?mt=8

Cancer.netGuidesto120cancers,interac0vetooltokeeptrackofques0onstoaskprovidersandrecordvoiceanswers,symptomtrackerforsideeffects.Link:hips://itunes.apple.com/us/app/cancer-net-mobile/id433501257?mt=8

NCCNGuidelinesforPa2ents

VirtualPa0entversionofNCCNGuidelines.Havetobecomeuser(free).Link:hips://itunes.apple.com/us/app/nccn-pa0ent-guides-for-cancer/id1168594706?mt=8

CancerSurvivorshipConnec2onByGeorgiaCoreLinkstoSurvivorsVideos,Blogs,AppsandCancerhospitalsinGeorgiaLink:hips://itunes.apple.com/us/app/cancer-survivorship-connec0on/id1189987382?mt=8

Pa2ent-orientedAPPS

ANDROID:

SymptomManagementGuidelinesByCancerCareOntarioSimplifiedguides(includesFa0gue)Link:hips://play.google.com/store/apps/details?id=com.cancercare.symptommanagement

Cancer.netGuidesto120cancers,interac0vetooltokeeptrackofques0onstoaskprovidersandrecordvoiceanswers,symptomtrackerforsideeffects.Link:hips://play.google.com/store/apps/details?id=com.fueled.cancernet

NCCNGuidelinesforPa2entsVirtualPa0entversionofNCCNGuidelines.Havetobecomeuser(free).Link:hips://play.google.com/store/apps/details?id=com.mediaparts.nccn

ThrombosisandCancer

•  Riskofvenousthromboembolism(DVTorPE)isincreasedinpa0entsreceivingcancerchemotherapy.

•  Inthegeneralpopula0on,VTEoccursatarateof1per1000persons/yearor0.1%(2/3DVT,1/3PE)andpa0entswithcancerhaveanincidenceofreportedthrombo0ceventsthatrangesfrom4%to20%

•  VTEispresentatautopsyinapproximately50%ofpa0entswithcancer•  Cancerpa0entshavearecurrencerateofthrombo0cevents30mesthatof

generalpopula0on•  Riskofvenousthromboembolismalsorisesprogressivelyoverthecourseof

treatment•  Retrospec0vestudieshavesuggestedanassocia0onbetweencancer-

associatedvenousthromboembolismandpa0entsurvival

KudererN,CulakovaE,LymanG,FrancisC,FalangaA,KhoranaA.(2016).AValidatedRiskScoreforVenousThromboembolismIsPredic0veof

CancerProgressionandMortality.TheOncologist,21;861-867

ThrombosisandCancer

•  Venousthromboembolismisthesecondleadingcauseofdeathfollowingcancerprogression

•  Mayresultindelayordiscon0nua0onofchemotherapy•  Thrombosisincancerpa0entshasanincreasedriskofrecurrent

eventsaswellasmajorbleedingincomparisontothrombosisinnon-cancerpa0ents

ClinicalRiskScore

Factor RiskScoreSiteofcancer

Veryhighrisk(stomach,pancreas)Highrisk(lung,lymphoma,gynecologic,bladder,tes0cular)

Prechemotherapyplateletcount≥350,000/mm3 1

Prechemotherapyleukocytecount>11,000/mm31

Hemoglobinlevel<10g/dLoruseofredcellgrowthfactors1

Bodymassindex≥35kg/m21

Cumula0vescore:highrisk,≥3;intermediaterisk,1-2;lowrisk,0.

ThrombosisandCancer

•  Alarge,na0onwide,prospec0vecohortstudyofadultswithsolidtumorsorlymphomaini0a0ngchemotherapyfrom2002to2006at115USprac0cesiteswasperformed.

•  Purposeofthestudywastoinves0gateiftheVTEClinicalRiskScorealsopredictedearlymortalityandcancerprogression

•  Duringthefirst4monthsoftherapyof4,405pa0ents,134(30%)diedand330(7.5%)experienceddiseaseprogression

Results

•  HighRiskPa0ents(n=540,12.3%)bytheClinicalRiskScorehada120daymortalityrateof12.7%

•  IntermediateRiskPa0ents(n=2,665,60.5%)hadamortalityrateof5.9%

•  LowRiskPa0ents(n=1,200,27.2%)hadamortalityrateof1.4%

120dayFollow-upResults:Cancerprogressionoccurredin27.2%ofhighriskpa0ents,16.4%ofintermediateriskpa0ents,and8.5%oflowriskpa0ents.

Conclusion

•  VTEClinicalRiskScorewasalsopredic0veofearlymortalityandcancerprogressionduringthefirstfourcyclesofoutpa0entchemotherapy.Thiswasalsoindependentofothermajorprognos0cfactorsincludingVTE.

Pa2entEduca2ononThrombosis

•  AmericanCollegeofPhysiciansPa0entEduca0onBookleton:WhatYouShouldKnowAboutBloodClots

“ADVTisabloodclotthatformsinthedeepveinsofyourbody,usuallyinthelegorarm.Iftheclotbreaksfreeandmovestothelungs,itcanblockbloodsupplyandmakeithardforoxygentogettotherestofyourbody.

ThisiscalledaPE.”

•  RiskFactorsYouCannotChange–  Havingafamilyhistoryofbloodclots(bloodrela0vewhohashad

bloodclotsinthepastorabloodcloKngdisorder)–  Beingover60yearsofage–  Apersonalhistoryofbloodclots

•  RiskFactorsYouCanWorktoChange–  Smoking–  Beingoverweightorhavingobesity

•  Mul0pleRiskFactorsthatYouMayHaveDuringYourLife0me–  Cancerdiagnosis

WhatYouShouldKnowAboutBloodClots:RiskFactors,Preven0on,andTreatment.(2016).AmericanCollegeofPhysicians,1-24

•  SymptomsofDVTandPE

•  Ac0onstotakeifhavingsymptomsofaDVTorPE

•  Waystopreventbloodclotsfromforming–  Importanceofregularexercise–  Smokingcessa0on–  Compressionstockings(Howtoapplyandtakeoff)

WarfinandOtherBloodThinners

Warfarin(Coumadin®) OtherBloodThinnersApixaban(Eliquis®),Dabigatran(Pradaxa®),Edoxaban(Savaysa®),Rivaroxaban(Xarelto®)

FoodInterac0ons

VitaminK—foundinleafygreenvegetables.Importanttoeatthesameamountandtypeeachweek.

Noknowninterac0onswithfood.

DrugInterac0ons

Over-thecounter:Herbalanddietarysupplements(ginger,ginsengandgarlic);an0-inflammatory(ibuprofenandnaproxen;coldmedicines).Prescrip2on:An0neoplas0c(cancer),heart,an0fungal,steroids,an0bio0cs,andan0depressantmedicines.

Talktoyourhealthcareprofessionalaboutpossibleinterac0onswithcurrentmedicines.Otherbloodthinnerscanhaveseveresideeffectsifnotmonitoredcorrectly.

BloodTests RequiresregularbloodtestscalledINRstomakesureyouareontherightdoseandthatyourbloodisnottoothickorthin.

Occasionalbloodteststomakesureyourblood,liver,andkidneysareworkingnormally.

Costs Lowercost(dependingonyourinsurancebenefits).

Highercost(dependingonyourinsurancebenefits).

PossibleSideEffects

Bleedingandbruising(talktoyourhealthcareprofessionalaboutyourriskforbleeding).

Bleedingandbruising(talktoyourhealthcareprofessionalaboutyourriskforbleeding).Possiblestomachdiscomfort.

Storage Canbestoredinapillorganizer. Dabigatranneedstobekeptinitsboile.Allotherscanbestoredinapillorganizer.

Prescrip2onMedica2ons

NameofMedicine Dosage Size,Shape

&ColorHowMuch

WhentoTake/HowtoUse

WhatIUseItFor

Start/StopDate Notes

Example:Warfarin 5mg small,oval,

peachcolor 1pill Takebymouth,everymorning BloodThinner 4/1/13-

Don'tskipdoses,beconsistentwithgreenveggies

Conclusion

•  Acancerdiagnosisisateachablemoment

•  Pa0enteduca0onpriortochemotherapyisessen0alandshouldfocusonpreven0onandtreatmentofsideeffectsaswellasinstruc0ononwhentoseekmedicalcare

•  Pa0entsshouldbeeducatedonthepossibilityofvenousthromboembolism(DVTorPE)andwaystopossiblypreventthisfromoccurringandthatitisamedicalemergency

•  Educa0onhelpspa0entsandtheircaregiversbebeieradvocatesfortheirwellbeing

EDUCATION FOR A BETTER CHEMOTHERAPY EXPERIENCE€¦ · van Dulmen S, Driesenaar J, van Weert J, van...

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