ocotober 2012, vol 3, no 5

© 2012 Green Hill Healthcare Communications, LLC

NAVIGATING PATIENTS ACROSS THE CONTINUUM OF CANCER CARETM

OCTOBER 2012 www.AONNonline.org VOL 3, NO 5

CLINICAL PRACTICEThe Impact of NurseNavigation on the PatientExperience

MEASURING OUTCOMESPatient Navigation: DefiningMetrics That Supportand Justify the NurseNavigator Position

REVIEW ARTICLEHelping Your PatientsManage Chemotherapy-Induced Nausea andVomiting

The median age of patients in the VISTA‡ trial was 71 years (range: 48-91).

Living Proof

VISIT US AT THE 2012 ADVANCED CONTENT CONFERENCE TO LEARN MORE

INDICATION

CONTRAINDICATIONS

WARNINGS, PRECAUTIONS, AND DRUG INTERACTIONS▼

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ADVERSE REACTIONS

Survival never gets old

VELCADE (bortezomib) Indication and Important Safety Information

Approved for subcutaneous and IV administration§

VELCADE® (bortezomib) delivered >13-month overall survival advantage in combination with MP* vs MP alone for previously untreated multiple myeloma (median 56.4 vs 43.1 months†; 60.1-month median follow-up‡)

CONTENT CONFERENCE

TO LEARN MORECONTENT CONFERENCE2012 ADVANCEDVISIT US AT THE

TO LEARN MORE2012 ADVANCED

y untreated multiple myeloma (median 56.4 vs 43.1 months

>13-month overall survival advantage in combination

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with MP* vs MP alone for previously untreated multiple myeloma (median 56.4 vs 43.1 months

(bortezomib) delivered >13-month overall survival advantage in combination

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; †with MP* vs MP alone for previously untreated multiple myeloma (median 56.4 vs 43.1 months

(bortezomib) delivered >13-month overall survival advantage in combination

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Approved for subcutaneous and IV administration


ication and Important Safety Information

VELCADE (bortezomib).with omen should aW▼



Pregnant women should beVELCADE (bortezomib).void becoming pregnant while being treaomen should a

§Approved for subcutaneous and IV administration


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ytopenia,thromboc constipanausea,

linical studies incin cMost commonly reported adverse reactions (incidence

ADVERSE REACTIONS

CYP3A4 inducers is not recommendedwith strong CYP3A4 inhibitors.Closely monitor pa▼

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anorexia andtric disorders, psychiaytopenia,thy peripheral neuropation, constipa

lude asthenic conditions,linical studies incMost commonly reported adverse reactions (incidence

ADVERSE REACTIONS

CYP3A4 inducers is not recommended Concomitant use of strongwith strong CYP3A4 inhibitors.

VELCADE in combinatients receiving Closely monitor pa

pprised of the potential harm to the fetus Pregnant women should beVELCADE (bortezomib).

anorexia and pyrexia, vomiting,,thy

diarrhea,lude asthenic conditions,30%)≥Most commonly reported adverse reactions (incidence

Concomitant use of strongtionVELCADE in combina

pprised of the potential harm to the fetus Pregnant women should be

Secondar.TTPP.was MP vs MP in previously untrea

y and safety of the efficac a randomized,A:VISTTA:‡

HR=0.695 (95% CI,†

*Melphalan+prednisone.

Please see Brief Summar

hareactions, Other adverse reactions,anemia.

decreased aytopenia,thromboc

existing

y of syncope,tientsng pa

mentted with ea

tientsa Pon. may occur –

and overall sur PFS, ORR,y endpoints were CR, Secondarted multiple myeloma (MM). previously untrea t

venously in combinaVELCADE administered intray and safety of tional phase 3 trial (N=682) evalua interna t open-label, a randomized,

<0.05.pp< 0.57-0.85); HR=0.695 (95% CI,*Melphalan+prednisone.

ADE on ney for VELCPlease see Brief Summar

ve been reported haluding serious adverse inc Other adverse reactions,

neuralgia, neutropenia,ppetite,decreased a anorexia andtric disorders, psychiaytopenia,

At a vival. and overall sury endpoint The primarted multiple myeloma (MM).

tion with enously in combina t ting trial (N=682) evalua t

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luding serious adverse and leukopenia,

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ter than t greaa The reconstituted concentra§VELCADE in addition.

Further enrollment was halted and paand ORR.VELCADE+MP vs 15.0 months with MP [resulted in significantly superior results for pre-specified interim analysis (median follo

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been reported

tion for IV administra the reconstituted concentra t tion for subcutaneous administra uted concentra t

ted analyses were performed. Upda t VELCADE in addition.tients re ther enrollment was halted and pa t

=0.000002]),pVELCADE+MP vs 15.0 months with MP [TTP (median 20.7 months with resulted in significantly superior results for w-up 16.3 months),pre-specified interim analysis (median follo

and overall sur PFS, ORR,y endpoints were CR, Secondar

tion (1 mg/mL). inistra t tion (2.5 mg/mL) is nistra ation (2.5 mg/mL) is

ted analyses were performed.tients receiving MP were offered

vival, overall sur PFS,TTP (median 20.7 months with

VELCADE+MP w-up 16.3 months),At a vival. and overall sur

Living Proof

Brief Summary

INDICATIONS:VELCADE® (bortezomib) for Injection is indicated for the treatment of patients with multiple myeloma. VELCADE is indicated for the treatment of patients with mantle cell lymphoma who have received at least 1 prior therapy.CONTRAINDICATIONS: VELCADE is contraindicated in patients with hypersensitivity to bortezomib, boron, or mannitol. VELCADE is contraindicated for intrathecal administration. WARNINGS AND PRECAUTIONS: VELCADE should be administered under the supervision of a physician experienced in the use of antineoplastic therapy. Complete blood counts (CBC) should be monitored frequently during treatment with VELCADE.Peripheral Neuropathy: VELCADE treatment causes a peripheral neuropathy that is predominantly sensory. However, cases of severe sensory and motor peripheral neuropathy have been reported. Patients with pre-existing symptoms (numbness, pain or a burning feeling in the feet or hands) and/or signs of peripheral neuropathy may experience worsening peripheral neuropathy (including ≥ Grade 3) during treatment with VELCADE. Patients should be monitored for symptoms of neuropathy, such as a burning sensation, hyperesthesia, hypoesthesia, paresthesia, discomfort, neuropathic pain or weakness. In the Phase 3 relapsed multiple myeloma trial comparing VELCADE subcutaneous vs. intravenous the incidence of Grade ≥ 2 peripheral neuropathy events was 24% for subcutaneous and 41% for intravenous. Grade ≥ 3 peripheral neuropathy occurred in 6% of patients in the subcutaneous treatment group, compared with 16% in the intravenous treatment group. Starting VELCADE subcutaneously may be considered for patients with pre-existing or at high risk of peripheral neuropathy.Patients experiencing new or worsening peripheral neuropathy during VELCADE therapy may benefit from a decrease in the dose and/or a less dose-intense schedule. In the single agent phase 3 relapsed multiple myeloma study of VELCADE vs. Dexamethasone following dose adjustments, improvement in or resolution of peripheral neuropathy was reported in 51% of patients with ≥ Grade 2 peripheral neuropathy in the relapsed multiple myeloma study. Improvement in or resolution of peripheral neuropathy was reported in 73% of patients who discontinued due to Grade 2 neuropathy or who had ≥ Grade 3 peripheral neuropathy in the phase 2 multiple myeloma studies. The long-term outcome of peripheral neuropathy has not been studied in mantle cell lymphoma.Hypotension: The incidence of hypotension (postural, orthostatic, and hypotension NOS) was 13%. These events are observed throughout therapy. Caution should be used when treating patients with a history of syncope, patients receiving medications known to be associated with hypotension, and patients who are dehydrated. Management of orthostatic/postural hypotension may include adjustment of antihypertensive medications, hydration, and administration of mineralocorticoids and/or sympathomimetics.Cardiac Disorders: Acute development or exacerbation of congestive heart failure and new onset of decreased left ventricular ejection fraction have been reported, including reports in patients with no risk factors for decreased left ventricular ejection fraction. Patients with risk factors for, or existing heart disease should be closely monitored. In the relapsed multiple myeloma study of VELCADE vs. dexamethasone, the incidence of any treatment-emergent cardiac disorder was 15% and 13% in the VELCADE and dexamethasone groups, respectively. The incidence of heart failure events (acute pulmonary edema, cardiac failure, congestive cardiac failure, cardiogenic shock, pulmonary edema) was similar in the VELCADE and dexamethasone groups, 5% and 4%, respectively. There have been isolated cases of QT-interval prolongation in clinical studies; causality has not been established.Pulmonary Disorders: There have been reports of acute diffuse infiltrative pulmonary disease of unknown etiology such as pneumonitis, interstitial pneumonia, lung infiltration and Acute Respiratory Distress Syndrome (ARDS) in patients receiving VELCADE. Some of these events have been fatal. In a clinical trial, the first two patients given high-dose cytarabine (2 g/m2 per day) by continuous infusion with daunorubicin and VELCADE for relapsed acute myelogenous leukemia died of ARDS early in the course of therapy. There have been reports of pulmonary hypertension associated with VELCADE administration in the absence of left heart failure or significant pulmonary disease. In the event of new or worsening cardiopulmonary symptoms, a prompt comprehensive diagnostic evaluation should be conducted.Reversible Posterior Leukoencephalopathy Syndrome (RPLS): There have been reports of RPLS in patients receiving VELCADE. RPLS is a rare, reversible, neurological disorder which can present with seizure, hypertension, headache, lethargy, confusion, blindness, and other visual and neurological disturbances. Brain imaging, preferably MRI (Magnetic Resonance Imaging), is used to confirm the diagnosis. In patients developing RPLS, discontinue VELCADE. The safety of reinitiating VELCADE therapy in patients previously experiencing RPLS is not known.Gastrointestinal Adverse Events: VELCADE treatment can cause nausea, diarrhea, constipation, and vomiting sometimes requiring use of antiemetic and antidiarrheal medications. Ileus can occur. Fluid and electrolyte replacement should be administered to prevent dehydration.Thrombocytopenia/Neutropenia: VELCADE is associated with thrombocytopenia and neutropenia that follow a cyclical pattern with nadirs occurring following the last dose of each cycle and typically recovering prior to initiation of the subsequent cycle. The cyclical pattern of platelet and neutrophil decreases and recovery remained consistent over the 8 cycles of twice weekly dosing, and there was no evidence of cumulative thrombocytopenia or neutropenia. The mean platelet count nadir measured was approximately 40% of baseline. The severity of thrombocytopenia was related to pretreatment platelet count. In the relapsed multiple myeloma study of VELCADE vs. dexamethasone, the incidence of significant bleeding events (≥Grade 3) was similar on both the VELCADE (4%) and dexamethasone (5%) arms. Platelet counts should be monitored prior to each dose of VELCADE. Patients experiencing thrombocytopenia may require change in the dose and schedule of VELCADE. There have been reports of gastrointestinal and intracerebral hemorrhage in association with VELCADE. Transfusions may be considered. The incidence of febrile neutropenia was <1%.Tumor Lysis Syndrome: Because VELCADE is a cytotoxic agent and can rapidly kill malignant cells, the complications of tumor lysis syndrome may occur. Patients at risk of tumor lysis syndrome are those with high tumor burden prior to treatment. These patients should be monitored closely and appropriate precautions taken.Hepatic Events: Cases of acute liver failure have been reported in patients receiving multiple concomitant medications and with serious underlying medical conditions. Other reported hepatic events include increases in liver enzymes, hyperbilirubinemia, and hepatitis. Such changes may be reversible upon discontinuation of VELCADE. There is limited re-challenge information in these patients.Hepatic Impairment: Bortezomib is metabolized by liver enzymes. Bortezomib exposure is increased in patients with moderate or severe hepatic impairment; these patients should be treated with VELCADE at reduced starting doses and closely monitored for toxicities.Use in Pregnancy: Pregnancy Category D. Women of childbearing potential should avoid becoming pregnant while being treated with VELCADE. Bortezomib administered to rabbits during organogenesis at a dose approximately 0.5 times the clinical dose of 1.3 mg/m2 based on body surface area caused post-implantation loss and a decreased number of live fetuses.

ADVERSE EVENT DATA: Safety data from phase 2 and 3 studies of single-agent VELCADE (bortezomib) 1.3 mg/m2/dose administered intravenously twice weekly for 2 weeks followed by a 10-day rest period in 1163 patients with previously treated multiple myeloma (N=1008, not including the phase 3, VELCADE plus DOXIL® [doxorubicin HCI liposome injection] study) and previously treated mantle cell lymphoma (N=155) were integrated and tabulated. In these studies, the safety profile of VELCADE was similar in patients with multiple myeloma and mantle cell lymphoma.In the integrated analysis, the most commonly reported adverse events were asthenic conditions (including fatigue, malaise, and weakness); (64%), nausea (55%), diarrhea (52%), constipation (41%), peripheral neuropathy NEC (including peripheral sensory neuropathy and peripheral neuropathy aggravated); (39%), thrombocytopenia and appetite decreased (including anorexia); (each 36%), pyrexia (34%), vomiting (33%), anemia (29%), edema (23%), headache, paresthesia and dysesthesia (each 22%), dyspnea (21%), cough and insomnia (each 20%), rash (18%), arthralgia (17%), neutropenia and dizziness (excluding vertigo); (each 17%), pain in limb and abdominal pain (each 15%), bone pain (14%), back pain and hypotension (each 13%), herpes zoster, nasopharyngitis, upper respiratory tract infection, myalgia and pneumonia (each 12%), muscle cramps (11%), and dehydration and anxiety (each 10%). Twenty percent (20%) of patients experienced at least 1 episode of ≥Grade 4 toxicity, most commonly thrombocytopenia (5%) and neutropenia (3%). A total of 50% of patients experienced serious adverse events (SAEs) during the studies. The most commonly reported SAEs included pneumonia (7%), pyrexia (6%), diarrhea (5%), vomiting (4%), and nausea, dehydration, dyspnea and thrombocytopenia (each 3%).In the phase 3 VELCADE + melphalan and prednisone study in previously untreated multiple myeloma, the safety profile of VELCADE administered intravenously in combination with melphalan/prednisone is consistent with the known safety profiles of both VELCADE and melphalan/prednisone. The most commonly reported adverse events in this study (VELCADE+melphalan/prednisone vs melphalan/prednisone) were thrombocytopenia (52% vs 47%), neutropenia (49% vs 46%), nausea (48% vs 28%), peripheral neuropathy (47% vs 5%), diarrhea (46% vs 17%), anemia (43% vs 55%), constipation (37% vs 16%), neuralgia (36% vs 1%), leukopenia (33% vs 30%), vomiting (33% vs 16%), pyrexia (29% vs 19%), fatigue (29% vs 26%), lymphopenia (24% vs 17%), anorexia (23% vs 10%), asthenia (21% vs 18%), cough (21% vs 13%), insomnia (20% vs 13%), edema peripheral (20% vs 10%), rash (19% vs 7%), back pain (17% vs 18%), pneumonia (16% vs 11%), dizziness (16% vs 11%), dyspnea (15% vs 13%), headache (14% vs 10%), pain in extremity (14% vs 9%), abdominal pain (14% vs 7%), paresthesia (13% vs 4%), herpes zoster (13% vs 4%), bronchitis (13% vs 8%), hypokalemia (13% vs 7%), hypertension (13% vs 7%), abdominal pain upper (12% vs 9%), hypotension (12% vs 3%), dyspepsia (11% vs 7%), nasopharyngitis (11% vs 8%), bone pain (11% vs 10%), arthralgia (11% vs 15%) and pruritus (10% vs 5%).In the phase 3 VELCADE subcutaneous vs. intravenous study in relapsed multiple myeloma, safety data were similar between the two treatment groups. The most commonly reported adverse events in this study were peripheral neuropathy NEC (38% vs 53%), anemia (36% vs 35%), thrombocytopenia (35% vs 36%), neutropenia (29% vs 27%), diarrhea (24% vs 36%), neuralgia (24% vs 23%), leukopenia (20% vs 22%), pyrexia (19% vs 16%), nausea (18% vs 19%), asthenia (16% vs 19%), weight decreased (15% vs 3%), constipation (14% vs 15%), back pain (14% vs 11%), fatigue (12% vs 20%), vomiting (12% vs 16%), insomnia (12% vs 11%), herpes zoster (11% vs 9%), decreased appetite (10% vs 9%), hypertension (10% vs 4%), dyspnea (7% vs 12%), pain in extremities (5% vs 11%), abdominal pain and headache (each 3% vs 11%), abdominal pain upper (2% vs 11%). The incidence of serious adverse events was similar for the subcutaneous treatment group (36%) and the intravenous treatment group (35%). The most commonly reported SAEs were pneumonia (6%) and pyrexia (3%) in the subcutaneous treatment group and pneumonia (7%), diarrhea (4%), peripheral sensory neuropathy (3%) and renal failure (3%) in the intravenous treatment group.DRUG INTERACTIONS: Bortezomib is a substrate of cytochrome P450 enzyme 3A4, 2C19 and 1A2. Co-administration of ketoconazole, a strong CYP3A4 inhibitor, increased the exposure of bortezomib by 35% in 12 patients. Therefore, patients should be closely monitored when given bortezomib in combination with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir). Co-administration of omeprazole, a strong inhibitor of CYP2C19, had no effect on the exposure of bortezomib in 17 patients. Co-administration of rifampin, a strong CYP3A4 inducer, is expected to decrease the exposure of bortezomib by at least 45%. Because the drug interaction study (n=6) was not designed to exert the maximum effect of rifampin on bortezomib PK, decreases greater than 45% may occur. Efficacy may be reduced when VELCADE is used in combination with strong CYP3A4 inducers; therefore, concomitant use of strong CYP3A4 inducers is not recommended in patients receiving VELCADE. St. John’s Wort (Hypericum perforatum) may decrease bortezomib exposure unpredictably and should be avoided. Co-administration of dexamethasone, a weak CYP3A4 inducer, had no effect on the exposure of bortezomib in 7 patients. Co-administration of melphalan-prednisone increased the exposure of bortezomib by 17% in 21 patients. However, this increase is unlikely to be clinically relevant.USE IN SPECIFIC POPULATIONS:Nursing Mothers: It is not known whether bortezomib is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from VELCADE, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.Pediatric Use: The safety and effectiveness of VELCADE in children has not been established.Geriatric Use: No overall differences in safety or effectiveness were observed between patients ≥age 65 and younger patients receiving VELCADE; but greater sensitivity of some older individuals cannot be ruled out.Patients with Renal Impairment: The pharmacokinetics of VELCADE are not influenced by the degree of renal impairment. Therefore, dosing adjustments of VELCADE are not necessary for patients with renal insufficiency. Since dialysis may reduce VELCADE concentrations, VELCADE should be administered after the dialysis procedure. For information concerning dosing of melphalan in patients with renal impairment, see manufacturer’s prescribing information.Patients with Hepatic Impairment: The exposure of bortezomib is increased in patients with moderate and severe hepatic impairment. Starting dose should be reduced in those patients.Patients with Diabetes: During clinical trials, hypoglycemia and hyperglycemia were reported in diabetic patients receiving oral hypoglycemics. Patients on oral antidiabetic agents receiving VELCADE treatment may require close monitoring of their blood glucose levels and adjustment of the dose of their antidiabetic medication.Please see full Prescribing Information for VELCADE at VELCADEHCP.com.

VELCADE, MILLENNIUM and are registered trademarks of Millennium Pharmaceuticals, Inc. Other trademarks are property of their respective owners.

Millennium Pharmaceuticals, Inc., Cambridge, MA 02139 Copyright © 2012, Millennium Pharmaceuticals, Inc.All rights reserved. Printed in USA V-12-0209 8/12

11:03 AM

Editor-in-ChiefLillie D. Shockney, RN, BS, MASUniversity Distinguished Service AssociateProfessor of Breast CancerDepts of Surgery and OncologyAdministrative Director, Johns HopkinsBreast Clinical ProgramsAdministrative Director, Johns HopkinsCancer Survivorship ProgramsAssociate Professor, JHU School ofMedicine, Depts of Surgery &Gynecology and ObstetricsAssociate Professor, JHU School of [email protected]

Section EditorsBreast CancerSharon Gentry, RN, MSN, AOCN, CBCNBreast Health NavigatorDerrick L. Davis Forsyth Regional Cancer Center

Prostate CancerFrank delaRama, RN, MS, AOCNSClinical Nurse SpecialistOncology/GenomicsCancer Care ClinicPalo Alto Medical Foundation

Healthcare Disparities Linda Fleisher, PhD, MPHAssistant Vice PresidentOffice of Health Communications & Health DisparitiesAssistant ProfessorCancer Prevention & ControlFox Chase Cancer Center

Health Promotion and OutreachIyaad Majed Hasan, MSN, FNPDirector and Nurse PractitionerSurvivorship Clinic and ProgramCleveland ClinicTaussig Cancer Center

AONN Research CommitteeMarcy Poletti, RN, MSN Program Administrator, Oncology ServicesWake Forest University Baptist Medical Center

Elaine Sein, RN, BSN, OCN, CBCNSenior Project ManagerFox Chase Cancer Center Partners

Penny Widmaier, RN, MSNNurse NavigatorBotsford Cancer Center

MISSION STATEMENTThe Journal of Oncology Navi gation &Survivorship (JONS) promotes reliance on evi-dence-based practices in navigating patients withcancer and their caregivers through diagnosis,treatment, and survivorship. JONS also seeks tostrengthen the role of nurse and patient navigatorsin cancer care by serving as a platform for theseprofessionals to disseminate original research find-ings, exchange best practices, and find support fortheir growing community.

Dear Colleague,

Iwant to begin by telling all of you how honored and proud I am to have been asked toserve as the Program Director for the Academy of Oncology Nurse Navigators(AONN). I am a strong advocate of navigation and survivorship and know that we canprovide the educational content, networking, and career development you need anddeserve as we move AONN forward. In the coming months and years, we will continueto focus on your needs and those of the patients you diligently navigate across the con-tinuum of care.What a treat for me, immediately following the announcement of my new role for the

organization, to then hold our 3rd annual AONN conference! More than 400 attendeescame together in Phoenix for the purpose of empowering themselves with even moreknowledge—knowledge communicated by an amazing lineup of expert speakers fromaround the country. The feedback I personally received was incredible, with commentssuch as “this is the best conference I have ever attended” and “how did you manage torecruit such top-notch speakers providing content that is all new and so valuable for us tolearn?” And this is only the beginning! We are already working on the agenda for our 4thannual conference, which will take place in mid November 2013 in Memphis. The con-tent will be very much driven by the survey feedback we received (and who knows—Elvismight be in the building!).But AONN is not just about holding a stellar annual conference. We are committed

to providing educational forums throughout the year, in this journal and in blogs online,which will be renamed “expert commentary” to more accurately reflect the content andits value for all of us. In addition, webinars will be created for you throughout the year ontopics that are critically important for you to be aware of and learn about—and that candirectly aid you in the wonderful work you do. AONN and the leadership and staff that make everything happen on your behalf want

to ensure that we are providing you value with your membership. So, anticipate receiv-ing in the coming months notifications about new Web site interactive features, the cre-ation of virtual interest groups on specialty areas (like specific organ-site cancers, such asbreast cancer), phases of navigation and survivorship (ie, surgical management, commu-nity outreach, survivorship care plans), and about the extensive work on our end to cre-ate a robust resource database that will provide access to special resources for patients

being navigated and supported by an AONN member.Enjoy reading the synopsis of our most recent confer-

ence, in case you missed it, and mark your calendars for ourmeeting in Memphis in 2013! g

With kind regards,

Lillie D. Shockney, RN, BS, MASEditor-in-Chief

AONN MOVINGFORWARD

Letters

from LILLIe

AONNONLINE.ORG JOURNAL OF ONCOLOGY NAVIGATION & SURVIVORSHIP 5

PUBLISHING STAFFSENIOR VICE PRESIDENT, SALES & MARKETING

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Journal of Oncology Navigation & Survivorship, ISSN 2166-0999 (print); ISSN 2166-0980 (online), is published 6 timesa year by Green Hill Healthcare Communications, LLC,1249 South River Road, Suite 202A, Cranbury, NJ 08512.Telephone: 732.656.7935. Fax: 732.656.7938. Copy right©2012 by Green Hill Health care Com muni cations, LLC.All rights reserved. Journal of Oncology Navigation &Survivorship logo is a registered trademark of Green HillHealthcare Communications, LLC. No part of this publica-tion may be reproduced or transmitted in any form or by anymeans now or hereafter known, electronic or mechanical,including photocopy, recording, or any informational stor-age and retrieval system, without written permission fromthe publisher. Printed in the United States of America.

EDITORIAL CORRESPONDENCE should be ad dressed to MANAGING EDITOR, Journal of OncologyNavigation & Survivorship (JONS), 1249 South River Road,Suite 202A, Cranbury, NJ 08512. E-mail: [email protected]. YEARLY SUBSCRIPTION RATES: United Statesand possessions: individuals, $50.00; institutions, $90.00; singleissues, $5.00. Orders will be billed at individual rate until proofof status is confirmed. Prices are subject to change withoutnotice. Correspondence regarding permission to reprint all orpart of any article published in this journal should be addressedto REPRINT PERMISSIONS DEPART MENT, GreenHill Healthcare Communications, LLC, 1249 South RiverRoad, Suite 202A, Cranbury, NJ 08512. The ideas and opinionsexpressed in JONS do not necessarily reflect those of the edito-rial board, the editorial director, or the publisher. Publication ofan advertisement or other product mention in JONS should notbe construed as an endorsement of the product or the manufac-turer’s claims. Readers are encouraged to contact the manufac-turer with questions about the features or limitations of theproducts mentioned. Neither the editorial board nor the pub-lisher assumes any responsibility for any injury and/or damageto persons or property arising out of or related to any use of thematerial contained in this periodical. The reader is advised tocheck the appropriate medical literature and the product infor-mation currently provided by the manufacturer of each drug tobe administered to verify the dosage, the method and durationof administration, or contraindications. It is the responsibility ofthe treating physician or other healthcare professional, relyingon independent experience and knowledge of the patient, todetermine drug dosages and the best treatment for the patient.Every effort has been made to check generic and trade names,and to verify dosages. The ultimate responsibility, however, lieswith the prescribing physician. Please convey any errors to theeditorial director.

ABOUT THE COVER

My Despair, My HopeAcrylic by a Person Diagnosed With Cancer, Indiana

I’ve always been the type of person who sees the glass half-full, but in theface of cancer, the emotional tug-of-war seems endless.

There is despair, after learning I have cancer. There is hope, knowing Iwill fight and do whatever is necessary to defeat this.

There is despair, because so much is unknown, so much is uncertain.But, there is hope, in the embrace of my family and friends, whose loveand support gives me strength.

Yet, now there is only hope. No other word encompasses all that I feeltoday.

OCTOBER 2012 • VOL 3, NO 5TABLE OF CONTENTS

CLINICAL PRACTICE

10 The Impact of Nurse Navigation on the PatientExperienceBy Jean A. McDonald, RN, MS; Patty Abella, RN, BSN

MEASURING OUTCOMES

16 Patient Navigation: Defining Metrics That Supportand Justify the Nurse Navigator PositionBy Ana Rosa Espinosa, DNP, MBA, RN, OCN; Molly Gabel, MD;

Pamela Vlahakis, RN, MSN, CBCN

REVIEW ARTICLE

22 Helping Your Patients Manage Chemotherapy-InducedNausea and VomitingBy Rosalie Canosa, LCSW-R; Sharon Gentry, RN, MSN, AOCN, CBCN

Correction: In the list of authors of the abstract “Role of Navigation and PatientEducation in the Treatment of Patients With Complex Cancers: Our ExperienceWith Head and Neck Cancer Patients,” published in our August issue, JacquelineMacLasco's degrees were misidentified. The correct listing is: Jacqueline MacLasco,RD, CDN.

6 OCTOBER 2012 • VOLUME 3, ISSUE 5 AONNONLINE.ORG

VELCADE and Millennium are registered trademarks of Millennium Pharmaceuticals, Inc. Other trademarks are property of their respective owners.

Millennium Pharmaceuticals, Inc., Cambridge, MA 02139

Copyright © 2010, Millennium Pharmaceuticals, Inc. All rights reserved. Printed in USA V-10-0196 11/10

*The VELCADE Reimbursement Assistance Program does not file claims or appeal claims for callers, nor can it guarantee that you will be successful in obtaining reimbursement

July 26-28, 2013Hyatt Regency La Jolla at Aventine

3777 La Jolla Village Drive San Diego, California

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Melanoma • Basal Cell Carcinoma • Cutaneous T-Cell Lymphoma Squamous Cell Carcinoma • Merkel Cell Carcinoma

SECOND ANNUAL CONFERENCE CO-CHAIRS

SANJIV S. AGARWALA, MDProfessor of Medicine

Temple University School of MedicineChief, Oncology & Hematology

St. Luke’s Cancer CenterBethlehem, PA

STEVEN J. O’DAY, MDHematology/Oncology Director of Clinical Research

Director of Los Angeles Skin Cancer Institute at Beverly Hills Cancer Center

Clinical Associate Professor of Medicine USC Keck School of Medicine

Adjunct Faculty, John Wayne Cancer InstituteBeverly Hills, CA

AXEL HAUSCHILD, MDProfessor of Dermatology

Department of DermatologyUniversity of Kiel

Kiel, Germany

www.CutaneousMalignancies.com

SAVE THE DATE • JULY 26-28, 2013

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Overview

In February 2012, MindStream Education1 held

a conference in Orlando, Florida, titled “BestPractices in Oncology Nurse Navigation.” Theconference was co-chaired by Lillie Shockney,RN, BS, MAS, a professor at Johns Hopkins whois also the Director of the Johns Hopkins ClinicalBreast Programs and Survivorship Programs aswell as editor-in-chief of the Journal of OncologyNavigation & Survivorship (JONS) and ProgramDirector for the Academy of Oncology NurseNavigators (AONN), and Julie Silver, MD, aphysician from Harvard Medical School who isan assistant professor in the Department ofPhysical Medicine and Rehabilitation. Therewere approximately 200 participants, includingprimarily oncology nurse navigators; however,physicians, administrators, and oncology socialworkers also attended. The focus of the conference was to highlight

the modern trend of oncology nurse navigationby presenting pioneering strategies and best prac-tice case studies from leading healthcare organi-zations. The large attendance reflects the desirefor information about nursing navigation as wellas the need for greater knowledge about programleadership and the operations of oncology servic-es. In a rousing brainstorming episode, Dr Silverled an interactive think-tank session in which allparticipants shared ideas on improving currentnavigation processes and care services for cancerpatients in order to provide the highest quality ofpatient care. She challenged the group to devel-op a strategy, using concrete evidence includingoutcomes, to convince their administration thatnavigation is a critical part of oncology care. Avolunteer group of conference participants, sev-eral of whom had expertise in academic publish-ing, teamed up to write the outcome of the dis-cussions and captured the following topics ofdiscussion:• What is the role of an oncology nurse naviga-tor?

• What barriers does an oncology nurse naviga-tor encounter?

• What strategies are or can be used to over-come the barriers?

• What are ways to track outcomes/metrics andhave them support or justify the oncologynurse navigator role?

• Are there other means to justify the oncologynurse navigator job?The 4 articles generated by the ideas from this

conference are ones that the authors hope willprovide insight on developing, maintaining, andimproving nurse navigation programs. Each arti-

cle is intended to assist programs in decipheringwhat they need in order to move their navigationprogram forward, incorporate best practices ofnavigation from leading healthcare organizations,and stimulate conversations among the disci-plines that support navigation programs to ensurethat navigation is included in the delivery ofquality cancer care. The first 2 of these articles are included in this

issue of JONS, and the others are slated to run inan upcoming issue of JONS. Thanks to the authorsfor their initiative and efforts in putting thistogether. g

REFERENCE1. Best Practices for Oncology Nurse Navigation Leadership -Spring Session, February 16-17, Orlando, FL. Mind StreamEducation Web site. www.mindstreamedu.com/past-conference-pages/nn1/. Accessed October 8, 2012.

The authors of the following 2 articles would liketo express a special thank you to Dr Julie Silver forthe challenge she presented and for her supportduring the manuscript production.

INTRODUCTIONAuthors respond to challenges posed at “Best Practices in OncologyNurse Navigation” Conference

Dr Silver led an interactive think-tanksession in which all participants sharedideas on improving current navigationprocesses and care services...


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We recognize that a diagnosis of cancercan be a life-changing event, with thejourney from diagnosis to survivorship,

and perhaps to end-of-life care, filled with fear,challenges, and uncertainties.1-3 The value ofpatient navigation provided by a highly experi-enced, knowledgeable, and compassionate oncol-ogy nurse can best be described by sharing com-ments and stories from patients who werefortunate to have been connected with a cancernurse navigator (CNN) as their cancer journeybegan.4-6 Being connected to and supported by a CNN

when newly diagnosed with cancer creates for thepatients and families a profound sense of securityand safety and helps to decrease fears and anxiety,thus allowing patients to effectively hear andprocess the tremendous amount of informationcoming at them.2,3 Informed and personalizeddecision making becomes more comfortable asthe CNN begins to outline what patients mayexperience as well as serve as their guide to sup-port their unique journey. Having a CNN shep-herding a patient’s care across the continuumusing the clinical expertise embedded in an evi-dence-based nursing practice is paramount toassure excellence in service and to optimize apatient-centered experience.1,7-9We all know that long after treatment is com-

pleted, and again as cancer survivors’ care isongoing, patients remember how we treatedthem, how we made them feel, and how we treat-ed their family and/or loved ones. Imagine thesense of comfort that patients treasure, knowingthat they are personally connected to a CNNwho, as their comments illustrate, made theirexperience so memorable, an experience that will

not be forgotten. Because this experience andconnection were so powerful, one can reasonablyassume that patients realized a deeper and moremeaningful sense of hope and healing, enablingthem to move forward with living beyond cancer,always mindful that the connection with theCNN would continue. The CNN is readily avail-able and will, at defined intervals, follow up toaddress the patients’ needs and concerns and pro-vide encouragement to optimize whole-personwell-being. The literature is robust in outlining the defini-

tion and value of providing patient-centeredcare.10,11 Likewise, most, if not all, healthcareorganizations today tout a care model thatembodies patient-centered care. Interestingly,when reviewing what organizations define aspatient-centered care, there is some consistency;however, most often significant variation exists,which likely results in patients having a differentexperience depending upon where their care wasprovided and by whom.A nurse navigation program has the potential

to be recognized as the hallmark model forpatient-centered care. The principles of patient-centered care as outlined in 1993 by Gertels andcolleagues10 and in 2001 by the Institute ofMedicine4 are embodied in a nurse navigationprogram. CNNs partner with patients and fami-lies through the care continuum, respect andhonor patients’ values and preferences, coordi-nate and integrate care, provide information andeducation, ensure that communication is seam-less, evaluate and intervene to provide physicalcomfort and emotional support, and coordinatecare transitions and continuity of care. To ensure this patient-centered care model is

THE IMPACT OF NURSENAVIGATION ON THEPATIENT EXPERIENCEBy Jean A. McDonald, RN, MSProHealth Care, Waukesha, Wisconsin

Patty Abella, RN, BSNAurora Health Care, West Allis, Wisconsin

Jean A. McDonald, RN, MS


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provided consistently to every patient regardlessof where navigation begins, it is imperative tostandardize the role of the CNN, with a consis-tent job description, standards, competencies,and educational preparation.12 The intent of stan-dardizing the CNN role is to define an evidence-based model with the most important dimensionsof care outlined in the framework to ensure thatpatients are evaluated consistently for care needsthat the evidence has identified as making a dif-ference. Key dimensions of care, includingpatient education, advocacy, identifying andremoving barriers, psychosocial management,and navigating and coordinating care across thecontinuum, have an impact on patient outcomes.The intended outcomes can be measured withconfidence and validity only when the naviga-tor’s role and key interventions are provided toevery patient regardless of disease state. Thedegree of care is dependent upon the individualneeds of the patient and family, with the CNNhaving the expertise to assess and plan the careneeds accordingly. By having a consistent frame-work, organizations can measure, quantify, andvalidate the impact of the navigation program. Data that demonstrate return on investment

speak to administrators. We are aware thatadministrators support navigation programs intheory; however, they are aware that these pro-grams are expensive and must be justified, thusthe need to drive consistency in practice.As reiterated in recent literature, the variance

in navigation programs and lack of standardizedprocedures continue to challenge researchers inthis field of study. Identifying key componentsrelevant to effective navigation programs isessential.13 There is also a gap in comparingpatient outcomes prospectively between patientswho do use navigation services and those who donot use or have access to navigation services.Again, this has merit only if variance in the roleis eliminated.12,13Likewise, nursing clinical practice must be

evidence based, with a clearly defined and out-come-driven, measurable clinical pathway. Datamust include patient satisfaction and, moreimportantly, quality-of-life (QOL) outcomes dueto the interventions of the CNN. Using a toolsuch as the National Comprehensive CancerNetwork distress thermometer to evaluate dis-tress at defined intervals would be invaluable inidentifying patient stressors that need to be man-

aged to impact QOL positively and ensurewhole-person care.3,14,15By being standardized and evidence based,

the navigation model will accelerate in terms ofneed and demand for the following reasons.Patients today are seeking out cancer programswith CNNs because they have heard from fami-ly or friends or perhaps on the program’s Website about the role of the CNN, and they wantto have a navigator with them to support andcoordinate all aspects of their care. As adminis-trators want to differentiate their cancer pro-grams from competitors, grateful and loyalpatients singing the praises of the CNNs willresult in increased administrative support for anavigation model. Second, a consistent naviga-tion model will support excellence in the

patient-centered experience and could serve asthe prototype of coordination for accountablecare expectations. Finally, cancer care accredit-ing bodies such as the Commission on Cancerare incorporating standards that outline expec-tations for patient navigation.7 In the CancerProgram Standards for 2012, standard 3.1 out-lines expectations for the patient navigationprocess. This standard must be fully implement-ed and will be surveyed in 2015. By providingstandardized, evidence-based care, organizationswill satisfy the accreditation requirements, mostlikely with commendation.Ever mindful of the resource challenges we are

all facing, grateful patients oftentimes becomegenerous donors to an organization’s foundation.Cancer patients often wish to “give back,” and doso in many ways, eg, volunteering or serving on apatient advisory council. Many times we miss agolden opportunity to ask for a charitable dona-tion to the foundation as tribute to the excellentcancer care received because of the CNN. Wealso have the opportunity to share patient storiesthat will touch the hearts of those who may not

We are aware that administrators support navigation programs in theory;however, they are aware that these programs are expensive and must bejustified...


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have been touched by cancer personally but wishto become a donor to support a navigation pro-gram because of the positive impact it has onpatients and families. Patient stories and comments are powerful and

compel us to pursue the development of naviga-tion programs. The following story, titled “TheNurse and the Navigator: I Should HaveKnown,” was written by a breast cancer survivor.The story captures poignantly the sole purposethis paper is intended to convey: every patientdeserves to experience a patient navigation pro-

gram, through a consistent, standardized, evi-dence-based clinical practice, delivered by anexperienced, knowledgeable, and compassionateoncology nurse. As you read this story, take noteof how the author describes the soul-touching dif-ference in her experience because of the CNNand the care team. I have read her story manytimes, and each time my emotions are triggered inyet another way that draws me to the absolutereason we need to have navigation programs inevery cancer program, to best serve the patient inproviding whole-person care.

The Nurse and the Navigator: I Should Have Known

You see, I should have known. I’m a nurseand worked with cancer nurse navigators. Ishould have known. Here is my story.On a fateful Friday afternoon, Dr W., a radi-

ologist, saw me after a second mammogram andasked if I wanted to do an ultrasound with biop-sy that very afternoon because he wanted moreinformation about what he saw on the mammo-gram. I wasn’t particularly alarmed becausewith a history of fibrocystic breast disease andmany negative aspirations, I merely thoughtthis would be another procedure that wouldturn out negative. However, I watched his eyesand the monitors and saw the expression in hiseyes change as the big black spots appeared onthe screen. I knew that something was amiss.As he took the biopsies from the middle of theblackness, my thoughts began to turn to thepossibility that I soon could be one of those 1 of8 women who have the diagnosis of breast can-cer sometime in their lifetime. He asked if Iwanted to be called on Saturday when theinformation came in or wait until Monday. Ofcourse I opted for Saturday. My husband had no idea of what had been

happening that afternoon. When I recountedthe events, I concluded with, “I won’t be sur-prised if the diagnosis is cancer when Dr W.calls tomorrow.”The call came at 8:30 Saturday morning. Dr

W.’s message was, “I have some good news andsome bad news. Which do you want to hearfirst?” I opted for the bad news, which was thatthe biopsy was positive for cancer. I honestlyhave no memory of what the good news was. Icouldn’t hear over the roar of the diagnosis of

cancer. He said he’d contact Dr K., a breast sur-geon, and I could talk with her immediatelyabout treatment options. I thanked him, heldmyself together until I could hang up, and thenmy husband and I hugged and cried.Immediately I went into my denial mode,thinking that of course it was detected earlybecause I’ve had regular mammograms, andeverything would be simple. By Monday, I was driven to get the treatment

started immediately. I called the only person Iknew who could help me, Jean McD, Directorof Cancer Services, and told her I was comingto see Dr K., the breast surgeon, immediately.Jean asked about setting me up with a cancernavigator and I said absolutely No!! I wanted tosee the surgeon TODAY, and I wanted to gettreatment started immediately. Jean knew justwhat to say to me, and what to do. While I wasdriving to the Women’s Center, I was trying sohard to say the words “I have cancer” out loud,without crying. I knew I needed to hold myselftogether to talk to people and to get help. Iyelled, whispered, hit the steering wheel, andprobably scared off drivers on 94 West who hadto assume the woman in that car was crazy. Andthey would have been right!When I got to the Women’s Center, Pam L.,

a cancer nurse navigator (CNN), interceptedme, took me back to her office, and began toscrape me off the walls and ceiling to talk withme about my findings and possible interven-tions. Pam magically found 2½ hours to be with me that day to talk through what the jour-ney could be like and what I needed to know totake the first baby steps. At no time did Pam


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ever get flustered, or act as if she had anythingelse to do that day. She was interrupted, exitedfor a few minutes, and came back, as if I werethe only patient in the world that day. Herknowledge of cancer and of how she could besthandle me and my reaction was so calming andcaring. At the end, she asked if I needed to seeDr K. that day or Tuesday. Dr K. was at anoth-er hospital but would come over later in theafternoon to see me if I couldn’t wait untilTuesday. I opted for Tuesday, because I was in a good

space after talking with Pam, and she had givenme lots of things to think about to organize myquestions when I met with Dr K. the next day.I should have known. As a nurse, I should

have known that nurses are there to do the car-ing and the physical/psychosocial support, andto educate patients so they can better care forthemselves. I did know that; but in my drive toquickly get this destructive creature out of mybreast as soon as possible, I wanted to see thesurgeon and get moving. Pam, as a trainedCNN, very gently and calmly took me underher wing and started to navigate the journeywith me, as a partner. I was a much more organ-ized and calm patient when I met with Dr K.the next day. Pam created this sense of empow-erment in me that, yes, I could get through this,and she would be there as my advocate everystep of the journey.But it didn’t stop there. I was not an easy

patient. Life was very complicated for me at thistime, and I had no time for cancer to appear inmy life. Our granddaughter was going to beborn in 3 weeks. I was leaving my position andinterviewing for another. And somehow, pre-opprocedures, surgery, and treatment had to beshoehorned between many unchangeable com-mitments. Dr K. gave my scheduling problemsto Pam to solve, and she solved them efficient-ly and always with a smile. Pam was there formy lumpectomy and subsequent mastectomy,and she listened as I complained continuallyabout my drains! My journey ended up being not as simple as I

had told myself it would be that first weekendafter Dr W. had given me the diagnosis. Forexample, the lumpectomy found more cancerthat hadn’t shown up on the diagnostic testing,more lymph glands were involved than initially

thought, and the final blow was that, after thesecond elective mastectomy, cancer cellsshowed up in the pathology report in spite of 12weeks of chemotherapy. Pam was there for methrough all of these developments. Sometimesshe would call me first and let me know theunexpected results the day before I met with DrK. Other times, Dr K. called first, followed by aphone call from Pam to make sure I understoodand to help plan the next steps. Chemo hadsome unexpected turns. Pam was always therechecking on me and working with Dr Q., amedical oncologist, and the nurses in the infu-sion center just as she did when surgery was theprimary treatment. And she followed methrough radiation. If I had faced all these unex-pected outcomes alone without Pam as my nav-igator, I promise you I would have been over-

whelmed with stress and would have comethrough this journey traumatized and discour-aged. Today I am stable, happy, and full of grat-itude for my luck in having a navigator to trulylead me through this experience. And now that I’m through the 11-month

journey, Pam and Dr K. are now starting a pro-gram for survivors to help people like me attendto the hard work of life after treatment. Dr N.,my radiation oncologist, once said to me thatthe hardest parts of the journey are when youget the diagnosis and when the treatment ends.I am assured now that I won’t be dropped, thatI will have a navigator with me for this nextchapter in the journey, and that I will be a bet-ter person for this.My sorrow comes from knowing that not all

patients have access to this level of care andnavigation. Thanks to Jean McD, the Directorof Cancer Services, I found Pam immediately.Other patients are picked up after surgery, orwhen they are in an acute crisis. I know that

As a nurse, I should haveknown that nurses arethere to do the caringand the physical/psychosocial support...


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In summary, a diagnosis of cancer can be a timeof transformation for a patient and her family.Supporting this challenging transformation, acancer nurse navigation program will balance theart and science of patient-centered care to ensurea sense of hope, healing, and security regardless ofthe outcome. g

Disclosures: Jean A. McDonald, RN, MS, has noconflict of interest or financial interest to dis-close. Patty Abella, RN, BSN, has no conflict ofinterest or financial interest to disclose.

REFERENCES1. Navigating difficult waters: the history of the patient navi-gators. American Cancer Society Web site. http://www.cancer.org/Cancer/news/Features/navigating-difficultwaters-the-history-of-the-patient-navigators. April 14, 2009. AccessedSeptember 30, 2012.2. Campbell C, Craig J, Eggert J, et al. Implementing and meas-uring the impact of patient navigation at a comprehensive com-munity cancer center. Oncol Nurs Forum. 2010;37(1):61-68.3. Dohan D, Schrag D. Using navigators to improve care ofunderserved patients: current practices and approaches. Cancer.2005;104(4):848-855.4. Institute of Medicine. Committee on Quality of Health Carein America. Crossing the Quality Chasm: A New Health System forthe 21st Century. Washington, DC: National Academies Press;2001.

5. Koh C, Nelson JM, Cook PF. Evaluation of a patient naviga-tion program. Clin J Oncol Nurs. 2011;15(1):41-48.6. Mandelblatt JS, Yabroff KR, Kerner JF. Equitable access tocancer services: a review of barriers to quality care. Cancer.1999;86(11):2378-2390. 7. Commission on Cancer. Cancer program standards 2012: ensur-ing patient-centered care. Standard 3.1 Patient navigation process.American College of Surgeons Web site. www.facs.org/cancer/coc/programstandards2012.pdf. Accessed Sep tember 29, 2012.8. Fillion L, de Serres M, Cook S, et al. Professional patientnavigation in head and neck cancer. Semin Oncol Nurs. 2009;25(3):212-221. 9. Freeman HP, Muth BJ, Kerner JF. Expanding access to can-cer screening and clinical follow-up among the medicallyunderserved. Cancer Practice. 1995;3(1):19-30.10. Gertels M, Edgman-Levitah S, Daley J, et al, eds. Throughthe Patient’s Eyes, Understanding and Promoting Patient-CenteredCare. San Francisco, CA: Jossey-Bass; 1993.11. Hegel MT, Moore CP, Collins ED, et al. Distress, psychiatricsyndromes, and impairment of function in women with newlydiagnosed breast cancer. Cancer. 2006;107(12):2924-2931.12. Hook A, Ware L, Siler B, et al. Breast cancer navigationand patient satisfaction: exploring a community-based patientnavigation model in a rural setting. Oncol Nurs Forum. 2012;39(4):379-385.13. Moore S. Making room at the table. Oncol Nurs Forum.2010;37(1):9. 14. Swanson J, Koch L. The role of the oncology nurse naviga-tor in distress management of adult inpatients with cancer: aretrospective study. Oncol Nurs Forum. 2010;37(1):69-76.15. Whelan TJ, Mohide EA, Willan AR, et al. The supportivecare needs of newly diagnosed cancer patients attending aregional cancer center. Cancer. 1997;80(8):1518-1524.

there are not enough Pams for everyone to behelped at the very beginning of treatment, butthere should be. It is only right that everyonewho goes through this journey have accessimmediately to the careful planning, advocacy,and organization that a navigator can provide.Physicians can’t do this work alone. It takes avillage. It’s been beautiful to watch the inti-mate teamwork that Pam and the physiciansdraw on to coordinate, guide, and navigatepatients through the long months of treatment

and survivorship.I should have known. I’m a nurse and know

what beautiful work nurses can do. But in mydistress, I just wanted to see Dr K. immediatelyto get surgery scheduled. I didn’t know all thepresurgical procedures that were necessary. Inow know firsthand the beautiful work that Pamand other nurse navigators can provide topatients. I am a stronger person today becausePam was there. If she were not there, I wouldhave fared much less well. I should have known!

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Influencing the Patient-Impact Factor

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Patient navigation emerged 2 decades ago, withnumerous articles reporting cancer care out-comes from the patient perspective, but its

effect on improving organizational outcomesrequires further research.1 However, according todata from the Oncology Roundtable’s MemberSurvey,2 almost 90% of cancer programs employ atleast 1 full-time equivalent navigator, and manyemploy more than one.Patient navigation incurs an initial economic

burden from (1) fixed costs: program development,policies, procedures, office space and furnishings,and patient materials; (2) indirect costs: telecom-munication, data collection and processing, pro-gram expenses related to patient-assistance activi-ties, electronic forwarding of medical records,copies of imaging studies provided in a trans-portable format; and (3) human resources: employ-ment (volunteer vs paid employee, clinical navi-gator vs lay navigator, full-time vs part-timenavi g ation), training (at orientation and continu-ing education), and supervisory/administrativecosts.3 Patient navigation also involves direct med-ical costs (patient charges that can be trackedthrough billing for prevention, screening, diagnos-tics, treatment, survivorship, and surveillancecare); nonmedical costs such as transportation andhelp with childcare; and indirect costs attributableto mortality/morbidity and loss of job or reducedwork productivity by the patient, friends, and/orfamily.3Before 2010, the primary motivations for

employing navigators were to enhance patientservice, remove barriers to care, and improve carecoordination. However, in 2010, the Commissionon Cancer codified the importance of navigationby adding the provision of navigation services to itsstandards for cancer program accreditation,Standard 3.1: “A patient navigation process, driv-en by a community needs assessment, is established

addressing health care disparities and barriers tocare for patients. Resources to address identifiedbarriers may be provided either on site or by refer-ral to community-based or national organiza-tions.”4 As a result, interest and investment in thisservice are expected to grow.Achieving patient-centered, high-quality can-

cer care is difficult to justify when time and moneyare required for services that are not directly reim-bursable.5 Common programmatic errors includeutilizing navigators to band-aid ineffective process-es, hiring staff without clearly defining organiza-tional needs, and not having an identified systemto track navigation revenue related to navigationservices.2 The Patient-Reported OutcomesWorking Group convened by the AmericanCancer Society’s National Patient NavigatorLeadership Summit defined core measures to guideresearch and programmatic evaluation. Demon -strating significant economic and clinical values isnecessary to advance patient navigation programs.3One of the most challenging aspects of manag-

ing a navigation program is designing a method formeasuring the impact of navigation services. Themetrics most commonly used to monitor naviga-tion include the number of patients receiving nav-igation services, overall patient satisfaction scores,and timeliness of care indicators. While each ofthese measures is potentially useful, none speaks tothe unique value that navigators add; rather, all ofthem measure aspects of patient care.2 Havingclearly defined goals and a measure of baseline per-formance for each key metric would be ideal.Selecting the appropriate measures can be difficultbut must be completed and refined before startingthe process of collecting data.

WHAT IS IMPORTANT TO PATIENTS?• An integrative and compassionate approach• A relationship of trust; knowing that someone

Patient Navigation: Defining Metrics That Support andJustify the Nurse Navigator PositionBy Ana Rosa Espinosa, DNP, MBA, RN, OCNUniversity of Miami School of Nursing and Health Studies, Miami, Florida

Molly Gabel, MDThe Cancer Institute of New Jersey/Robert Wood Johnson University Hospital, New Brunswick, New Jersey

Pamela Vlahakis, RN, MSN, CBCNHunterdon Regional Cancer Center, Flemington, New Jersey

Ana Rosa Espinosa, DNP, MBA,RN, OCN


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they trust will carry them throughout thisjourney

• Access to care in an efficient time frame• Appropriate referral networks, including ap -propriate referral pathways

• Coordination of services throughout the con-tinuum of care

• Assistance with obtaining medical records• Individualized prescreening for potential clin-ical trials

• Coordination of all appointments, eg, radia-tion, chemotherapy

• Education that is relevant to their disease pro -cesses/treatments

• Individual support for their family members • Access to additional services, including nutri-tional counseling, psychosocial counseling,complementary medicine, and educationaland nursing care services, and assistance inworking with community organizations

Patients and families tell us countless times howmuch the patient navigator helped. We, as naviga-tors, help maintain the patient’s sense of controlduring a very stressful time by providing informa-tion, paving the way with appointment scheduling,answering questions that our patients may have,and providing a consistent point of contact for ourpatients throughout their cancer treatment andafterwards. However, as care providers, we are also responsi-

ble for frequently evaluating our care programsusing objective outcome metrics. Taking a targetedapproach is important to definitively proving thevalue of the navigation program. By completingthese evaluations, we not only make informeddecisions regarding program design but we also canprovide our administration with the objective dataneeded to support us.

MEASURING OUTCOMES OF PROGRAMMATIC SUCCESSWhen choosing the data to prove a point, also

look at the literature and speak to administratorsat your institution. Using terms or measures thatthe healthcare industry can understand will makeyour job easier. Validating your data is important,as this will help build a program that yourpatients, your institution, accreditation bodies,and insurance providers will value. Simplify thedata collection to look at 1 or 2 prenavigationand postnavigation program data points. Eachone selected should, on its own, prove beyond a

doubt that the navigation program is responsiblefor the improvement.

QUESTIONS TO POSE WHEN CHOOSINGOUTCOME METRICSWhen meeting the needs of the patient, will my

work increase patient volume and/or revenue atthe hospital? • Limit the use of satisfaction surveys to naviga-tor-specific patient satisfaction tools and usedata from the survey not only to assess patientsatisfaction but also to identify opportunitiesto refine your navigation program.

• When analyzing how your patient navigationprogram will increase revenue for the hospital:– Measure out-migration of patients by includ-ing a question on your baseline survey andall current program surveys. Many patientsleave the system to seek second opinionsbecause they do not have a person who will

assist with making a decision or while navi-gating through the many treatments andprocedures, thus making a difference in thepatient experience. Responses that differfrom the presence of a navigation programwill help you elucidate that factor.– Do not track the distance from the patient’sresidence to the facility (patients vary great-ly in their willingness to travel for care, andthese data are not easily translatable to dif-ferent regions of the country).– Do not simply track referral patterns for allreferring physicians (who have relationshipsor preconceptions that you alone cannotovercome). However, getting physician sup-port is crucial for the success of the naviga-tion program and to measure patient satis-faction with and without a navigationprogram.– Do not track the number of specific proce-dures performed regardless of stage of canceror patient preference (which might prove tobe stronger factors than navigation alone).

However, as care providers, we are alsoresponsible for frequently evaluatingour care programs using objective outcome metrics.

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Addressing the Factor Measuring Reliable Factors How to Collect the Data

Overcoming Barriers

Provide assistance with • The number of “no shows” at treatment • EMR: automated reports of transportation or follow-up appointments cancellations

• Lost revenue from missed appointments • No EMR: receptionist records on or out-migration written log daily

• Captured charges for each patient provided with transportation to treatment

Financial counselor • The number of patients counseled • Captured charges (rates or per assistance with obtaining relative to the amount of reimbursed patient)insurance coverage care given

• Reviewing federally funded programs for enrollment (eg, CEED grant for screening affords access to Medicare when diagnosed)

Appropriateness of Care

Successful management of • Emergency room visits within 30 days • Billing datatreatment toxicity of discharge for target ICD-9 codes

• Readmission within 30 days of discharge for same admitting diagnosis

Clinical outcomes of • Local tumor control • Tumor registrar or chart reviewcancer care • Survival rates • Tumor registrar

• Functional status • Psychosocial distress tool• Toxicity rates • Chart review or ICD-9 query

Improved patient compliance • Admissions by common toxicity (eg, • Admissions by ICD-9 for specific through education constipation, nausea and vomiting, problemand communication diarrhea, pain)

Improved patient • Precounseling and postcounseling • Manually or through SurveyMonkey comprehension and comfort comprehension tests or other Web-based toolwith care plan • Addition of navigation protocols for specific

domains of care, ie, transitioning from surgeon to oncologist6

Assurance of appropriate, • Surveillance laboratory test, procedure • CPT codestimely surveillance care after or physician visits for physical exam treatment (to prevent compared with national guidelinesoverutilization or underutilization)

Improved enrollment in • Number enrolled per total number seen • Clinical trial data management clinical trials (best to measure for a specific patient system or written records

population)

Improve referrals for genetic • Number of referrals on site • EMRcounseling and cancer risk • Number of referrals to another facility or • Referral databaseassessment community-based organization

Table Patient Care Outcome Metrics to Evaluate the Patient Navigator Program


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Patient Satisfaction

Improve access to care; • Median and range of wait times from • EMR: date from pathology diagnosis decrease patient wait times cancer diagnosis to subspecialist physician to patient appointment

• Start of definitive treatment (surgery, • No EMR: manual collectionchemotherapy, hormonal manipulation, • Tumor registrar or radiation)

Improve patient satisfaction • Validated satisfaction tool • Make sure oncology specialty with care • Use specific tool you design for your services are monitored separately

care process rather than grouped with ambulatoryservices or other general group• Involve many people in design; acknowledge as a not-yet-validated tool• Monitor gifts from grateful patients/families

Improve patient access to • Referrals to health professionals such as • Billing data or manual trackingservices that enhance comfort social workers, physicians, by gender, or

other patient requests, nutrition, pain management, cancer rehabilitation

Employee Satisfaction

Improve employee • Physician satisfaction • Customized tool asking how satisfaction to decrease • Nurse (non-navigator) satisfaction navigator role makes physicians turnover, providing more • Physician productivity or nurses more efficientconsistent care for patients • RVU prenavigation and and preventing cost of postnavigationemployee replacement

Increasing Revenue

Prevention of patient • Care delivered within or outside system • Tumor registrar data, zip code data, out-migration as measured by the proportion of patients or manual tracking

leaving the system • CPT codes with physician input • Track only patients leaving the system by cancer primary siteand estimate lost revenue according to evidence-based guidelines

Increase “downstream • Laboratory or radiology tests, support • Billing data (technical and revenue” for patients with services, hospice care, cancer rehabilitation, professional)cancer treated at your evidence-based cancer surveillance care institution procedures (colonoscopy, follow-up physical

exams)

Ensure cancer-specific • Procedure-specific incremental revenue • Billing data (technical and program growth (prenavigation and postnavigation) professional)

Improve care provider • Volume of patients treated/undergoing • Captured charges (most meaningful productivity procedures (prenavigation and to hospital administration)

postnavigation) • Physician- or physician group-specific RVU

Abbreviations: CEED, Center for the Elimination of Disparities; EMR, electronic medical record; RVU, relative value unit.

Table Patient Care Outcome Metrics to Evaluate the Patient Navigator Program (Continued...)

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How can maintaining the confidentiality ofpatient and provider feedback contribute to thesuccess of the program? • Maintaining confidentiality is especiallyimportant when using patient or staff satisfac-tion surveys but should also be considered dur-ing focus or support groups. Constructive crit-icism is needed but will be gained only whenthose asked feel safe in sharing their opinions.

Will this measure prove that the programimproves treatment outcomes?• Select measures that demonstrate improvedoutcomes through evidence-based care (betteryet, can you provide the new benchmark orstandard of care?). This information can beused both for marketing campaigns and innegotiating contracts for care.

• Be sure to keep the data you measure simple;the more complex the data, the greater theopportunity for confounding variables.Measuring the use of 1 treatment for a specif-ic stage of cancer is better than looking at gen-eral outcomes for all patients with that type ofcancer.

After refining what you want to measure foreach specific question, thinking of your completeddata as being able to tell a story that combinespatients’ psychosocial and medical needs with theneeds of the institution and/or care providers ishelpful. Choose measures that are different fromone another, and you will be sure to have a story totell rather than a lecture on 1 aspect of care thatmight not interest everyone in your audience. Last February, Mindstream Education held a

meeting in Orlando during which the panelists andthe audience came up with several measures andmetrics to validate the benefits of patient naviga-tion. Several general themes evolved with sugges-tions on how to monitor the collected data. TheTable shows how the data should be collected, as abaseline before the navigation program exists orbefore any proposed enhancements, and thenreported on a schedule that most relates to theurgency of the problem.Being diagnosed with cancer can be devastat-

ing because patients worry about the unknownand what the future may hold for them. Cancerpatients are compromised initially with the bur-den of a cancer diagnosis, and their coordinationof care is yet another unnecessary stressor. Familycaregivers for cancer patients experience high

levels of stress and burden and diminished qualityof life. Ongoing research in the search for a curehas resulted in increased treatment options andmultiple modalities; consequently, the coordina-tion of treatments and services has become exten-sive and complex for patients and their families.In addition, exploring the best treatment options,such as clinical trials, procedures, and new drugs,without guidance can become cumbersome andoverwhelming. Inadvertently, this causes delaysin access to care, diagnosis, education, and treat-ment. How can a nurse navigator help? He or shecan help by moving the patient smoothly throughthe healthcare system during the continuum of care.As patient navigation services evolve and

expand, nurses and social workers in oncologyhave roles in educating patients, survivors, fami-lies, healthcare teams and systems, and the publicabout patient navigation. Challenges revolvearound measuring and ensuring desired and opti-mal outcomes for patients, families, survivors, andindividuals in patient navigator roles and processesto address sustainability of navigation programsand services.7g

Disclosures: Ana Rosa Espinosa, DNP, MBA, RN,OCN, has no conflict of interest or financial inter-est to disclose. Molly Gabel, MD, has no conflictof interest or financial interest to disclose. PamelaVlahakis, RN, MSN, CBCN, has no conflict ofinterest or financial interest to disclose.

REFERENCES1. Paskett EH, Harrop JP, Wells KJ. Patient navigation: an updateon the state of the science. CA Cancer J Clin. 2011;41:237-249.2. Oncology Roundtable. Maximizing the value of patient naviga-tion. The Advisory Board Company Web site. http://www.advisory.com/Research/Oncology-Roundtable/Studies/2011/Maximizing-the-Value-of-Patient-Navigation. Accessed September 25, 2012.3. Whitley E, Valverde P, Wells K, et al. Establishing common costmeasures to evaluate the economic value of patient navigation pro-grams. Cancer. 2011;117(15 suppl):3618-3625. 4. American College of Surgeons Commission on Cancer. CancerProgram Standards 2012: Ensuring Patient-Centered Care. Chicago,IL: American College of Surgeons; 2011.5. Delivering on the promise of patient-centered care: designingservices to support the whole patient. The Advisory Board Com -pany Web site. http://www.advisory.com/Research/Oncology-Roundtable/Studies/2011/Delivering-on-the-Promise-of-Patient-Centered-Care. Accessed October 6, 2012.6. Pedersen A, Hack TF. Pilots of oncology health care: a conceptanalysis of the patient navigator role. Oncol Nurs Forum.2010;37(1):55-60.7. Wells KJ, Battaglia TA, Dudley DJ, et al. Patient navigation:state of the art or is it science? Cancer. 2008;113(8):1999-2010.

CALL FOR PAPERSThe Journal of Oncology Navigation & Survivorship® (JONS), launched in 2010, is the nation’s first peer-reviewed clinical journal for Oncology Nurse Navigators. As this critical area of specialty and expertise grows,research and sharing of best practices are integral to both improving the clinical care of cancer patients as wellas expanding the existing literature and knowledge base. Our goal at JONS is to help facilitate that growth.

Readers are invited to submit articles that fit into the following topics:

Papers can be in the following form:• Original Research• Review Article (a synopsis/review of current literature in a specific area of research)• Case Study• “How To” article designed to transfer successes to fellow practitioners

Each manuscript is subject to an internal review to see that it fits the scope of and mission of our journal. Papers that pass the initial review could be subject to a blinded peer review; final acceptance is based on that review.

If you are interested in submitting a paper or have any questions, please feel free to contact our editorial department [email protected] or [email protected].

• Patient Education• Continuity of Care• Screening Programs• Community Outreach• Psychosocial Issues• Emotional Support• Facilitation of Treatment Decision Making • Tumor Board Processes• Caring for the Underserved

• Navigation Processes and Outcomes Measures• Working with a Multidisciplinary OncologyTeam

• Transitional Processes into Survivorship Care• Long-Term Follow-Up• Patient Surveillance• Patient Adherence• Any other topic relevant and of importanceto the specialty

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INTRODUCTIONAs healthcare professionals who work with

people living with cancer, we often see patientswhen they are most vulnerable. For manypatients, their moments of greatest vulnerabilityare at the time of diagnosis and while discussingtreatment. During such moments, patients typi-cally feel overwhelmed and inundated with alarge amount of information to process and assim-ilate, while at the same time dealing with theemotional impact of a cancer diagnosis. Much ofthat information consists of basics on their type ofcancer and the recommended course of therapy,including instructions on adhering to the thera-peutic regimen. Not surprisingly, information andinstructions from doctors and nurses may not befully integrated, or may easily get “scrambled,”during such a tender time. Patients may thereforelack a full understanding of the importance of fol-lowing those instructions, or may even forgetthem. While forgetting or not fully understandingdisease-related information may have tremendousramifications for many aspects of cancer care, itcan be particularly impactful when dealing withthe nausea and vomiting that is often caused bychemotherapy.

CHEMOTHERAPY-INDUCED NAUSEA ANDVOMITING: THE SCOPE OF THE PROBLEMThe benefits of cytotoxic chemotherapy are

undisputed. It is a type of therapy that has extend-ed the lives of untold millions of cancer patients.Yet chemotherapy is often associated withunpleasant side effects that negatively affectpatients’ quality of life. One of the more debilitat-ing side effects is chemotherapy-induced nauseaand vomiting (CINV), a term that describes thesymptoms of nausea and vomiting that occur inreaction to chemotherapeutic agents.1 For cancerpatients receiving chemotherapy or radiationtherapy, CINV can compromise or negate thebenefits of treatment by making it very difficult

for the patient to adhere to the therapeutic regi-men, or by triggering an interruption or delay oftreatment.While all patients undergoing chemotherapy

are at risk of CINV, there are numerous factorsthat can heighten a patient’s risk of this dreadedcomplication. Such risk factors include2,3: • Age less than 50 years• Being female• Low alcohol intake (one or fewer drinks perday)

• History of motion sickness, or of morningsickness with pregnancy

• Fear of nausea from chemotherapy or a histo-ry of CINV

• Anxiety or nausea associated with past stress • Current use of antidepressants or antianxietymedication

There are also numerous treatment-related fac-tors that can affect the incidence and severity ofCINV. These include the dosage, schedule, androute of administration of the chemotherapy reg-imen; the level of emetogenicity (likelihood ofcausing vomiting) of the regimen; the use of mul-tiple agents in the regimen; and multiple cycles ofchemotherapy.2,4 Chemo therapeutic agents canbe categorized according to emetogenicity. Highlyemetogenic chemotherapy (HEC) denotes a regi-men that induces emesis (vomiting) in more than90% of patients in the absence of effective pro-phylactic antiemetic therapy,4 although onlyabout 30% of these patients will vomit if theyreceive antiemetic prophylaxis before administra-tion of HEC.3,5,6 A moderately emetogenicchemotherapy (MEC) regimen is one that carriesa 30% to 90% risk of emesis.4 Regimens carryinga low risk of emesis are those that induce emesisin only 10% to 30% of patients, and treatmentswith minimal emetogenic risk cause emesis in lessthan 10% of patients.4While CINV is quite common, its incidence

can vary greatly and is difficult to determine. In a

Helping Your Patients Manage Chemotherapy-InducedNausea and VomitingBy Rosalie Canosa, LCSW-RProgram Division Director, CancerCare

Sharon Gentry, RN, MSN, AOCN, CBCNBreast Nurse Navigator, Derrick L Davis Forsyth Regional Cancer Center, Winston-Salem, North Carolina

Sharon Gentry, RN, MSN, AOCN,CBCN

Rosalie Canosa, LCSW-R


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1996 clinical trial, CINV was reported in 47 of 48patients (98%) receiving HEC without antiemet-ic therapy.7 In a 2004 trial in which 298 patientswere treated with antiemetics while receivingMEC or HEC, one-third of the participants expe-rienced acute nausea (ie, that which occurs with-in a few minutes to several hours after a chemo -therapy dose), and the incidence of delayednausea (ie, more than 24 hours after chemothera-py administration) was 60%.8 In a 2005 study of857 women with breast cancer who receivedantiemetic prophylaxis while on MEC, half of thepatients experienced CINV.9 Although the inci-dence of CINV has declined over the past decade,CINV remains a threat to patients with cancer. CINV can have a profound impact on patients’

quality of life, potentially leading to metabolicimbalances, a decline in patients’ self-care andfunctional ability, worsening of patients’ perfor-mance status and mental status, nutrient deple-tion, anorexia, surgical wound dehiscence (burst-ing open or splitting), esophageal tears, andpatients’ refusal, delaying, or prevention of addi-tional therapy.10-13 CINV can also impose a signif-icant socioeconomic burden by reducing employ-ee productivity and boosting overall healthcarecosts due to prolonged hospitalization andincreased nursing expenses.14 A recent retrospec-tive study calculated the mean cost of a CINV-related hospital visit at $5299, with a mean per-patient cost of $731.15

THE VALUE OF ANTIEMESISIn our experience, CINV is easier to prevent

than to treat. Many patients experience cancer asa chronic disease, and can benefit from the use ofantiemetic medications during all phases of treat-ment. A variety of antiemetic agents are avail-able, including those that can be administered bythe oral, rectal, intravenous (IV), intramuscular,or transdermal route. IV agents may be appropri-ate for patients who are unable to swallow ordigest tablets due to emesis, while others maybenefit from having antiemetic medication deliv-ered via a transdermal patch, which may helpreduce the pill burden and simplify treatment forthese patients. The National ComprehensiveCancer Network, in its latest antiemesis treat-ment guidelines,4 cautions that while some stud-ies suggest that certain agents are equally effectiveon a population basis, individual patients mayrespond differently, and a patient’s individual

experience may drive the selection of antiemesistherapy.Serotonin (5-HT3) antagonists, a class of

agents that includes dolasetron mesylate,granisetron, ondansetron, and palonosetron, arecommonly used for the prevention and treatmentof CINV. The oral and IV forms of these agentshave been shown to have equivalent efficacywhen administered at the appropriate doses,16,17and granisetron is also available as a transdermalpatch with demonstrated effectiveness for up to 5days from first application. Another common pre-ventive regimen is a “cocktail” containing theneurokinin-1 (NK-1) receptor antagonist aprepi-tant (or its IV version fosaprepitant), the corti-costeroid dexamethasone, and a benzodiazepineagent such as olanzapine.4 Other types of agents,

such as phenothiazines, benzamides, antihista-mines, butyrophenones, and cannabinoids, havealso been used for antiemesis, although these havelargely been replaced by the 5-HT3 antagonists.4

CHALLENGES IN ADHERING TOANTIEMETIC MEDICATION REGIMENSOnce a patient has started chemotherapy, anx-

iety and emotional stress may complicate anyefforts to adhere to antiemesis therapy. This isespecially true of patients having their first expe-rience with chemotherapy, although it may stillbe a lingering issue through subsequent rounds.All too often, when a patient is taught what toexpect from chemotherapy, she nods and appearsto understand the educational information and issent home after round one. Three days later shefeels sick and anxious. She may be experiencing a“drop-off” effect from the antiemesis regimen, ormay not have taken the drugs as instructed. Evenif she followed instructions, the drugs may nothave worked as expected. “I don’t know what todo,” she says, adding that she feels so bad that theemergency room (ER) seems a reasonable option.Two key nursing actions can help the patient

Many patients experience cancer as achronic disease, and can benefit fromthe use of antiemetic medications during all phases of treatment.

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through this vulnerable time. The first action isthe “teach-back” method (also known as the“show-me” method or “closing the loop”), whichmust be undertaken before the patient leaves herfirst chemotherapy treatment session.18 Once thepatient has been briefed on strategies to manageCINV, the “teach-back” method largely consistsof asking the patient questions such as, “Tell mewhat you are going to do if you feel nauseous orhave uncontrolled vomiting.” The patient’sanswers may reveal that she did not fully under-stand the information you have provided and thatmore information is required. In such situations,chances are that the patient’s anxiety and insecu-

rity made her afraid to speak up during the brief-ing, or that she does not feel comfortable enoughto ask questions about the antiemesis medicationand its accompanying instructions. Wheneverpossible, it is important that the briefing includefamily members or whoever will be with thepatient after treatment. The second key action is to have a nurse navi-

gator or clinical nurse call the patient at homeafter treatment. A review of the educational con-tent, as well as an assessment of the efficacy of theantiemesis medications, can confer a measure ofcontrol to the patient at this critical time.Documentation of “real-time” symptoms can leadto needed medication changes prior to the nextcycle of treatment. In a 2010 article, Sprandiodocumented how a community oncology practiceachieved a drop in ER visits as well as a decreasein unscheduled office visits when this qualitycheck was implemented.19 The resulting cost sav-ings from avoiding CINV-related hospital visitscan thus be an important metric for nurse naviga-tors to support their role. Sometimes, financial difficulties can interfere

with patients’ efforts to adhere to antiemetic ther-apy. For some patients, the cost of treatment issimply too high. Others may struggle to pay the

co-pay, even if their insurance covers the rest ofthe cost. As a result, patients may skip or delay anantiemesis dose, an omission that can have aruinous effect on their quality of life, not to men-tion their chemotherapy experience as a whole.Some patients may have limited access toantiemesis treatment. A lack of reliable trans-portation may make it difficult, if not impossible,to get to the doctor’s office, clinic, or pharmacy.Needless to say, a patient will have trouble adher-ing to a medication regimen if he lacks the meansto obtain it. The role of the social worker or nursenavigator is critical in identifying such patients sofinancial issues can be addressed before theybecome a concern.Oftentimes, adherence to antiemesis therapy is

compromised by patients’ misperceptions of treat-ment. Fear of addiction (the risk of which is min-imal with antiemesis medications) is a powerfulforce in our society, and some patients may opt toforgo antiemesis medication rather than endurethe perceived stigma of being “on drugs.”

ENHANCING COMMUNICATIONThe challenges of managing CINV make it

crucial for the oncology nurse, nurse navigator,and oncology social worker to encourage patientsto communicate proactively with the health pro-fessionals who are coordinating their care. Weneed to tell patients not to be afraid to speak up ifthe antiemesis medication is not working, or ifthey do not fully understand the instructions fortaking it. We need to make it clear that it’s OK toask questions, and that a patient should not waituntil the next appointment or next round ofchemotherapy to raise her concerns.In our experience, treatment-related informa-

tion needs to be reinforced repeatedly. Not only isit important to ask patients if they truly under-stand what is expected of them, but it is alsoimportant to follow up and ask if they have beentaking the medication as directed. Before theyleave the clinic, it is helpful to have patientsrepeat the instructions back to you to make surethey understand them.The importance of adhering to antiemesis med-

ication cannot be overemphasized. We need tohelp patients overcome whatever fears or beliefsmay be preventing them from adhering toantiemetic therapy. None of these fears or beliefs isa reason for any cancer patient to have to endureCINV, or to refuse or delay antiemesis therapy.

The challenges of managing CINVmake it crucial...to encourage patientsto communicate proactively with the health professionals who are coordinating their care.


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Above all, patients need to feel empoweredand equipped with the information they need tohelp them manage their disease. Organizationssuch as CancerCare offer a variety of educationalresources specifically focusing on CINV (seeBox). It is our obligation to share that informa-tion; we cannot assume that people will get itfrom some other source. At the same time, weneed to work to ensure patients have the finan-cial, logistical, and emotional support they needto access their medications and supportive careresources. In some cases, that support may consistof connecting patients with co-pay assistance pro-grams, compassionate-use initiatives, or clinicaltrials. In other cases, we can help arrange trans-portation, or facilitate the involvement of familymembers, friends, or other caregivers to ease theburden on the cancer patient. If we are to givepatients permission to be proactive in managingtheir disease, we must be proactive ourselves inhelping them.

CONCLUSIONFrom the time of diagnosis, the patient with

cancer embarks upon a life-changing journeymarked by multiple rounds of treatment and fol-low-up. The journey may include treatmentresponse and cancer remission. On the otherhand, the itinerary for the journey may change toaccount for disease progression and downstreamtreatment options. In most cases, the patient hasnot planned for this journey and may feel vulner-able, alone, and unprepared for the inevitablebumps in the road. If managed correctly andappropriately, CINV is a bump that can be avoid-ed, or at least made less disruptive to the patient’slife. As oncology nurses, nurse navigators, andpatient advocates, we are in an important posi-tion to help patients negotiate those challengesby providing and reinforcing treatment- and sup-portive care-related information, facilitatingcommunication with doctors and other healthprofessionals, and encouraging patients to beproactive in managing the various aspects of theircare. In so doing, we can demonstrate to ourpatients that they are not alone. By serving astrusted guides, we may be able to make the cancerjourney a bit less harrowing. g

Disclosures: Rosalie Canosa, LCSW-R, has noconflict of interest or financial interest to dis-close. Sharon Gentry, RN, MSN, AOCN,

CBCN, has no conflict of interest or financialinterest to disclose.

REFERENCES1. Chemotherapy-induced nausea and vomiting. Mosby’s Med -ical Dictionary, 8th ed. Elsevier, Inc; 2009. TheFree DictionaryWeb site. http://medical-dictionary.thefreedictionary.com/chemotherapy-induced+nausea+and+vomiting. Accessed June 25,2012.2. Stricker CT, Eaby-Sandy B. Chemotherapy-induced nauseaand vomiting. In: Brown CG, ed. A Guide to Oncology SymptomManagement. Pittsburgh, PA: Oncology Nursing Society;2010:91-122.3. Hesketh PJ, Grunberg SM, Herrstedt J, et al. Combined datafrom two phase III trials of the NK1 antagonist aprepitant plus a5HT3 antagonist and a corticosteroid for prevention ofchemotherapy-induced nausea and vomiting: effect of gender ontreatment response. Support Care Cancer. 2006;14(4):354-360.4. National Comprehensive Cancer Network. NCCN ClinicalPractice Guidelines in Oncology: Antiemesis. Version 1.2012.http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Accessed November 7, 2011.5. Hesketh PJ, Kris MG, Grunberg SM, et al. Proposal for clas-sifying the acute emetogenicity of cancer chemotherapy. J ClinOncol. 1997;15(1):103-109.6. Roila F, Herrstedt J, Aapro M, et al. Guideline update forMASCC and ESMO in the prevention of chemotherapy- andradiotherapy-induced nausea and vomiting: results of thePerugia consensus conference. Ann Oncol. 2010;21(suppl 5):v232-v2343.

Helping patients manage CINV:CancerCare educational resources• Connect® Education workshops and pod-casts:–Advances in Treating Chemotherapy-Related Nausea and Vomiting– Understanding and Managing Chemo therapy Side Effects

• Publications– Coping With Nausea and Vomiting FromChemotherapy

– Tips for Managing Nausea and IncreasingAppetite During Cancer Treatment

– Understanding and Managing Chemo -therapy Side Effects

– “Doctor, Can We Talk?” Tips for Com - municating With Your Health CareTeam

• Online forums– Ask CancerCare: experts answer ques-tions about coping with cancer

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7. Kris MG, Cubeddu LX, Gralla RJ, et al. Are more antiemet-ic trials with a placebo necessary? Report of patient data fromrandomized trials of placebo antiemetics with cisplatin. Cancer.1996;78(10):2193-2198.8. Grunberg SM, Deuson RR, Mavros P, et al. Incidence ofchemotherapy-induced nausea and emesis after modernantiemetics: perception versus reality. Cancer. 2004;100(10):2261-2268.9. Warr DG, Hesketh PJ, Gralla RJ, et al. Efficacy and tolera-bility of aprepitant for the prevention of chemotherapy-inducednausea and vomiting in patients with breast cancer after mod-erately emetogenic chemotherapy. J Clin Oncol. 2005;23(12):2822-2830.10. Laszlo J. Emesis as limiting toxicity in cancer chemothera-py. In: Laszlo J, ed. Antiemetics and Cancer Chemotherapy.Baltimore, MD: Williams & Wilkins; 1983:1-5.11. Ingle RJ, Burish TG, Wallston KA. Conditionability of cancerchemotherapy patients. Oncol Nurs Forum. 1984;11(4):97-102.12. Mitchell EP. Gastrointestinal toxicity of chemotherapeuticagents. Semin Oncol. 1992;19(5):566-579.13. Richardson JL, Marks G, Levine A. The influence of symp-toms of disease and side effects of treatment on compliance with

cancer therapy. J Clin Oncol. 1988;6(11):1746-1752.14. O’Brien BJ, Rusthoven J, Rocchi A, et al. Impact of chemo -therapy-associated nausea and vomiting on patients’ functionalstatus and on costs: survey of five Canadian centres. CMAJ.1993;149(3):296-302.15. Burke TA, Wisniewski T, Ernst FR. Resource utilization andcosts associated with chemotherapy-induced nausea and vomit-ing (CINV) following highly or moderately emetogenic chemo -therapy administered in the US outpatient hospital setting.Support Care Cancer. 2011;19:131-140.16. Kris MG, Gralla RJ, Clark RA, et al. Incidence, course, andseverity of delayed nausea and vomiting following the adminis-tration of high-dose cisplatin. J Clin Oncol. 1985;3(10):1379-1384.17. Kris MG, Hesketh PJ, Somerfield MR, et al. American So -ciety of Clinical Oncology guideline for antiemetics in oncolo-gy: update 2006. J Clin Oncol. 2006;24(18):2932-2947.18. North Carolina Program on Health Literacy. HealthLiteracy Toolkit. Tool 5. http://www.nchealthliteracy.org/toolkit/tool5.pdf. Accessed September 7, 2012.19. Sprandio JD. Oncology patient-centered medical home andaccountable cancer care. Commun Oncol. 2010;7(12):565 -572.

SAVE THE DATE

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