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.
Kinnane,N.,&Thompson,L.(2008).Evalua0onoftheaddi0onofvideo-basededuca0onforpa0entsreceivingstandardpre-chemotherapyeduca0on.
EuropeanJournalofCancerCare,17(4),328-339
Pa2entSelec2on
• Pa0entswithcolorectalcancerandwerescheduledtoreceiveadjuvantchemotherapywithweekly5FluorouracilandFolinicAcid
• Pa0entswithbreastcancerandwerereceiving5Fluorouracil,EpirubicinandCyclophosphamideorAdriamycin/EpirubicinandCyclophosphamideChemotherapy
• Pa0entshadEnglishastheirprimarylanguage
• ECOGscore0-2
Kinnane,N.,&Thompson,L.(2008).Evalua0onoftheaddi0onofvideo-basededuca0onforpa0entsreceivingstandardpre-chemotherapyeduca0on.
EuropeanJournalofCancerCare,17(4),328-339
ExclusionCriteria
• Iftheyoranyimmediatefamilymemberhadpriorchemotherapy
• Comorbidcondi0onthatwouldprohibitcomprehensionandgivinginformedconsent
• Visuallyorhearingimpaired
• Unabletocompletetheques0onnaire
Kinnane,N.,&Thompson,L.(2008).Evalua0onoftheaddi0onofvideo-basededuca0onforpa0entsreceivingstandardpre-chemotherapyeduca0on.
EuropeanJournalofCancerCare,17(4),328-339
WithdrawalCriteria
• Pa0entswerewithdrawniftheyhadtoxici0esthatrequiredstoppingtreatment
• Iftreatmenthadtobedeferredduetoseriousillnesslas0ngmorethan3weeks
Kinnane,N.,&Thompson,L.(2008).Evalua0onoftheaddi0onofvideo-basededuca0onforpa0entsreceivingstandardpre-chemotherapyeduca0on.
EuropeanJournalofCancerCare,17(4),328-339
"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
Kinnane,N.,&Thompson,L.(2008).Evalua0onoftheaddi0onofvideo-basededuca0onforpa0entsreceivingstandardpre-chemotherapyeduca0on.
EuropeanJournalofCancerCare,17(4),328-339
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
KudererN,CulakovaE,LymanG,FrancisC,FalangaA,KhoranaA.(2016).AValidatedRiskScoreforVenousThromboembolismIsPredic0veof
CancerProgressionandMortality.TheOncologist,21;861-867
ClinicalRiskScore
Factor RiskScoreSiteofcancer
Veryhighrisk(stomach,pancreas)Highrisk(lung,lymphoma,gynecologic,bladder,tes0cular)
21
Prechemotherapyplateletcount≥350,000/mm3 1
Prechemotherapyleukocytecount>11,000/mm31
Hemoglobinlevel<10g/dLoruseofredcellgrowthfactors1
Bodymassindex≥35kg/m21
KudererN,CulakovaE,LymanG,FrancisC,FalangaA,KhoranaA.(2016).AValidatedRiskScoreforVenousThromboembolismIsPredic0veof
CancerProgressionandMortality.TheOncologist,21;861-867
Cumula0vescore:highrisk,≥3;intermediaterisk,1-2;lowrisk,0.
ThrombosisandCancer
• Alarge,na0onwide,prospec0vecohortstudyofadultswithsolidtumorsorlymphomaini0a0ngchemotherapyfrom2002to2006at115USprac0cesiteswasperformed.
• Purposeofthestudywastoinves0gateiftheVTEClinicalRiskScorealsopredictedearlymortalityandcancerprogression
• Duringthefirst4monthsoftherapyof4,405pa0ents,134(30%)diedand330(7.5%)experienceddiseaseprogression
KudererN,CulakovaE,LymanG,FrancisC,FalangaA,KhoranaA.(2016).AValidatedRiskScoreforVenousThromboembolismIsPredic0veof
CancerProgressionandMortality.TheOncologist,21;861-867
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.
KudererN,CulakovaE,LymanG,FrancisC,FalangaA,KhoranaA.(2016).AValidatedRiskScoreforVenousThromboembolismIsPredic0veof
CancerProgressionandMortality.TheOncologist,21;861-867
Conclusion
• VTEClinicalRiskScorewasalsopredic0veofearlymortalityandcancerprogressionduringthefirstfourcyclesofoutpa0entchemotherapy.Thiswasalsoindependentofothermajorprognos0cfactorsincludingVTE.
KudererN,CulakovaE,LymanG,FrancisC,FalangaA,KhoranaA.(2016).AValidatedRiskScoreforVenousThromboembolismIsPredic0veof
CancerProgressionandMortality.TheOncologist,21;861-867
Pa2entEduca2ononThrombosis
• AmericanCollegeofPhysiciansPa0entEduca0onBookleton:WhatYouShouldKnowAboutBloodClots
“ADVTisabloodclotthatformsinthedeepveinsofyourbody,usuallyinthelegorarm.Iftheclotbreaksfreeandmovestothelungs,itcanblockbloodsupplyandmakeithardforoxygentogettotherestofyourbody.
ThisiscalledaPE.”
Pa2entEduca2ononThrombosis
• RiskFactorsYouCannotChange– Havingafamilyhistoryofbloodclots(bloodrela0vewhohashad
bloodclotsinthepastorabloodcloKngdisorder)– Beingover60yearsofage– Apersonalhistoryofbloodclots
• RiskFactorsYouCanWorktoChange– Smoking– Beingoverweightorhavingobesity
• Mul0pleRiskFactorsthatYouMayHaveDuringYourLife0me– Cancerdiagnosis
WhatYouShouldKnowAboutBloodClots:RiskFactors,Preven0on,andTreatment.(2016).AmericanCollegeofPhysicians,1-24
Pa2entEduca2ononThrombosis
• SymptomsofDVTandPE
• Ac0onstotakeifhavingsymptomsofaDVTorPE
• Waystopreventbloodclotsfromforming– Importanceofregularexercise– Smokingcessa0on– Compressionstockings(Howtoapplyandtakeoff)
WarfinandOtherBloodThinners
WhatYouShouldKnowAboutBloodClots:RiskFactors,Preven0on,andTreatment.(2016).AmericanCollegeofPhysicians,1-24
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
WhatYouShouldKnowAboutBloodClots:RiskFactors,Preven0on,andTreatment.(2016).AmericanCollegeofPhysicians,1-24
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