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Adoption of evidence remains slow, leading to variations in practices and quality of care. Examining evidence-based interventions implemented within oncology settings can guide knowledge translation efforts.This integrative review aimed to (1) identify topics implemented for oncology-related evidence-based practice (EBP) change; (2) describe frameworks, guidelines, and implementation strategies used to guide change; and (3) evaluate project quality.PubMed and CINAHL were searched to identify published practice change projects. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Fifty articles met the inclusion criteria. Data were extracted; content analysis was conducted. The Quality Improvement Minimum Quality Criteria Set guided quality assessment.Topics included infection control/prevention (n = 18), pain/palliative care (n = 13), psychosocial assessment (n = 11), and medication adherence (n = 8). Among the projects, Plan, Do, Study, Act (n = 8) and Lean Six Sigma (n = 6) frameworks were used most. Thirty-six projects identified guidelines that directed interventions. Multiple implementation strategies were reported in all articles with planning, education, and restructuring the most common. Reach, sustainability, and ability to be replicated were identified as quality gaps across projects.The EBP topics that emerged are consistent with the oncology nursing priorities, including facilitating integration of EBP into practice. The studies identified used national guidelines and implementation strategies to move evidence into practice. Heterogeneity in measurement made synthesis of findings difficult across studies, although individual studies showed improvement in patient outcomes.Development of an interprofessional oncology consortium could facilitate a standardized approach to implementation of high-priority topics that target improved patient outcomes, harmonize measures, and accelerate translation of evidence into practice.

Despite the high incidence of constipation in people with cancer, there is little research on management strategies for opioid-induced constipation (OIC). This project used the Plan-Do-Study-Act model to examine implementation of the Oncology Nursing Society GuidelinesTM to improve constipation management in patients with cancer. Nurse champions at four sites identified practice gaps, including providing education on OIC for patients who are new to opioids and increasing follow-up assessment. This project demonstrates that multisite, collaborative projects are feasible and may enhance patient quality of life and decrease anticipated complications.

PURPOSE: This evidence-based guideline intends to support patients, clinicians, and others regarding interventions and processes to support patient adherence to oral anticancer medications (OAMs). METHODOLOGIC APPROACH: A panel of healthcare professionals and patient representatives developed a clinical practice guideline to support patients taking OAMs. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology and criteria for trustworthy guidelines were followed. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A quantitative or narrative synthesis of the evidence was completed. Certainty of the evidence was assessed using GRADE. FINDINGS: The panel agreed on recommendations and suggested an adherence risk assessment, education addressing adherence, ongoing assessment, proactive follow-up, coaching, and motivational interviewing in addition to usual care. The panel suggested the implementation of a structured OAM program. IMPLICATIONS FOR NURSING: As cancer treatment shifts from clinic to home settings, interventions and programs to support patients on OAMs are needed.

PROBLEM IDENTIFICATION: An interprofessional approach is necessary to support the multifactorial process of patient adherence to oral anticancer medications (OAMs). This scoping review aims to identify structured OAM programs in published literature, identify components within studies, and propose a framework for institutions developing or maintaining OAM programs. LITERATURE SEARCH: Embase(®), PubMed(®), and CINAHL(®) databases were searched for studies published between January 2000 and April 2021. DATA EVALUATION: Two reviewers screened studies and extracted data. Characteristics and specific domains of the OAM programs were captured. Key components of the programs were identified, and a framework was created to guide program development. SYNTHESIS: Components identified among the 21 studies were education; counseling; follow-up; dedicated clinician contact; adverse event and toxicity monitoring; adherence monitoring; drug procurement, delivery, and supply; patient- and system-level cost reduction; information technology; and risk assessment. IMPLICATIONS FOR RESEARCH: Based on the findings, a framework for building and evaluating OAM adherence programs is proposed. Future studies should evaluate the reliability and validity of this framework because further testing may lead to the development of additional components.

Telehealth use has increased in the setting of the COVID-19 pandemic. However, there are disparities in telehealth use based on age, income, race/ethnicity, low health, digital literacy, and limited English proficiency. There are multilevel barriers to telehealth use at the patient, health systems, telehealth portal, and policy levels. To ensure equity in telehealth services and to leverage these services to maximize the reach of health care services, concerted efforts are needed to design telehealth tools and workflows. It should include reimbursement for staff training, patient education, and technical support needed for telehealth use. Furthermore, ongoing monitoring and responsive modifications in the use of telehealth services are needed to promote telehealth equity.

The development of rigorous, high-quality clinical guidelines increases the need for resources and skilled personnel within guideline-producing organizations. While collaboration between organizations provides a unique opportunity to pool resources and save time and effort, the collaboration presents its own unique challenges. To assess the perceived needs and current challenges of guideline producers worldwide related to guideline development and collaboration efforts. Survey questions were developed by the Guidelines International Network and the US GRADE Network, pilot-tested among attendees of a guideline development workshop, and disseminated electronically using convenience and snowball sampling methods. A total of 171 respondents representing 30 countries and more than 112 unique organizations were included in this analysis. The survey included free-response, multiple-choice, and seven-point Likert-scale questions. Questions assessed respondents’ perceived value of guidelines, resource availability and needs, guideline development processes, and collaboration efforts of their organization. Time required to develop high-quality systematic reviews and guidelines was the most relevant need (median=7; IQR=5.5–7). In-house resources to conduct literature searches (median=4; IQR=3–6) and the resources to develop rigorous guidelines rapidly (median=4; IQR=2–5) were perceived as the least available resources. Difficulties reconciling differences in guideline methodology (median=6; IQR=4–7) and the time required to establish collaborative agreements (median=6; IQR=5–6) were the most relevant barriers to collaboration between organizations. Results also indicated a general need for improvement in conflict of interest (COI) disclosure policies. The survey identified organizational challenges in supporting rigorous guideline development, including the time, resources, and personnel required. Connecting guideline developers to existing databases of high-quality systematic reviews and the use of freely available online platforms may facilitate guideline development. Guideline-producing organizations may also consider allocating resources to hiring or training personnel with expertise in systematic review methodologies or utilizing resources more effectively by establishing collaborations with other organizations.

This systematic review compared the efficacy of interventions to usual care on adherence to oral anticancer regimens.Embase®, PubMed®, and CINAHL® were searched for eligible comparative studies published between January 2000 and May 2021. Outcomes of interest included adherence, cancer-related morbidity, quality of life, patient satisfaction, and other patient-specific outcomes.Reviewers assessed risk of bias using the Cochrane Risk of Bias 2 tool and Risk of Bias in Nonrandomized Studies of Interventions. Certainty of evidence was assessed using the GRADE framework.Risk assessment, ongoing or periodic assessment, proactive follow-up, motivational interviewing, or structured programs may improve adherence. Education or coaching interventions may improve or have little to no effect on adherence. Technological interventions may improve adherence, but interactive compared to noninteractive technology may have little to no effect.As more cancer treatments move to oral formulations, work remains to identify the most effective interventions to support people receiving oral anticancer regimens.

Approximately 50%-70% of patients with cancer will receive radiation therapy. Radiodermatitis is one of the most common side effects of radiation therapy, with as many as 95% of patients experiencing some degree of skin change. Radiodermatitis can cause pain, itching, and burning and potentially has a significant impact on a patient's quality of life. If radiodermatitis becomes severe, it can cause treatment interruption. The prevalence of radiodermatitis coupled with the effect this side effect can have on quality of life prompts the need for evidence-based recommendations for management.

Purpose This evidence-based guideline intends to support clinicians, patients, and others in decisions regarding the treatment of constipation in patients with cancer. Methodologic approach An interprofessional panel of healthcare professionals with patient representation prioritized clinical questions and patient outcomes for the management of cancer-related constipation. Systematic reviews of the literature were conducted. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess the evidence and make recommendations. Findings The panel agreed on 13 recommendations for the management of opioid-induced and non-opioid-related constipation in patients with cancer. Implications for nursing The panel conditionally recommended a bowel regimen in addition to lifestyle education as first-line treatment for constipation. For patients starting opioids, the panel suggests a bowel regimen as prophylaxis. Pharmaceutical interventions are available and recommended if a bowel regimen has failed. Acupuncture and electroacupuncture for non-opioid-related constipation are recommended in the context of a clinical trial. Supplementary material can be found at https //bit.ly/30y29sI.

Purpose Radiodermatitis is a side effect of radiation therapy. Evidence-based interventions to minimize severity or delay progression are important for clinical care. This guideline intends to support individuals with cancer, clinicians, and others in decisions regarding radiodermatitis treatment. Methodologic approach A panel of healthcare professionals with patient representation was convened to develop a national clinical practice guideline for the management of radiodermatitis. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology and the National Academies of Sciences, Engineering, and Medicine criteria for trustworthy guidelines were followed. The Cochrane Collaboration risk-of-bias tool was used, and certainty of the evidence was assessed using the GRADE approach. A quantitative and narrative synthesis of the evidence was completed. Findings The panel agreed on eight recommendations and made a conditional recommendation for deodorant/antiperspirant. Aloe vera and oral curcumin had knowledge gaps and were recommended only in the context of a clinical trial. The panel suggested against emu oil, calendula, and nonsteroidal interventions. Implications for nursing This guideline summarizes evidence-based interventions for the management of radiodermatitis to guide clinical care. Supplementary material can be found at https //bit.ly/2GEwJtT.

Problem identification A systematic review and meta-analysis was conducted to inform the development of guidelines on the management of radiodermatitis among patients with cancer. Literature search The authors updated a systematic review to include available literature published through September 30, 2019. Data evaluation Two investigators assessed risk of bias using the Cochrane Collaboration risk-of-bias tool and certainty of the evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Synthesis The use of deodorant/antiperspirant had no effect on development of radiodermatitis. Aloe vera and emu oil were equivalent or less effective than standard care. Oral curcumin had a minimal beneficial effect. Nonsteroidal topical interventions had a minimal beneficial effect on the development of moist desquamation and relief of itching while causing a small increase for grade 2 radiodermatitis. Topical calendula increased risk for the development of radiodermatitis. Topical steroids and dressings each showed benefits to minimize the development of radiodermatitis and moist desquamation while lowering rates of patient-reported symptoms, such as pain and pruritus. Implications for research Symptom management strategies for radiodermatitis among patients with cancer that are likely to be effective include topical nonsteroidals, topical steroids, and dressings. Supplemental material can be found at https //bit.ly/2FWj3Kp.

To present and discuss care domains (oncologic, cardiometabolic, aging, behavioral, environmental) for clinicians when approaching care for a breast cancer survivor at risk for developing breast cancer–related lymphedema (BCRL), as well as survivors who have been diagnosed with BCRL. Assessment using each domain aids in decision-making, yet also identifies barriers to pursuing personalized care for survivors with BCRL. BCRL occurs from damage to the lymphatics during breast cancer treatment and occurs in approximately 20 to 40% of survivors. Prospective surveillance and early treatment for BCRL are supported in the literature; however, these approaches are frequently not used within evidence-based recommendations. The five domains can be used to develop a personalized plan of BCRL care. Barriers to pursuing personalized care for survivors with BCRL are identified. Future work in developing evidence-based recommendations is needed to guide clinicians and survivors during prospective surveillance, successful risk reduction, early diagnosis, and treatment of BCRL.

Problem identification The comparative effectiveness of available management options for cancer-related secondary lymphedema is unknown. Literature search CINAHL®, Embase®, and MEDLINE® were searched for randomized trials comparing conservative treatment strategies. Data evaluation A network meta-analysis was conducted for lymphedema volume, along with pairwise meta-analyses for remaining outcomes. Evidence certainty was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Synthesis Overall, 36 studies with a total of 1,651 participants were included. Compared to standard care, conservative treatments did not significantly reduce lymphedema volume. There was low to very low certainty evidence of benefit for several treatments on secondary outcomes. Implications for practice There is insufficient evidence to suggest important differences between standard care and conservative treatment strategies for reducing lymphedema volume and improving lymphedema-related symptoms. Supplemental material can be found at https //onf.ons.org/supplementary-material-conservative-intervention-strategies-adult-cancer-related-lymphedema.

Despite the success and ongoing promise of monoclonal antibody-targeted immune checkpoint inhibitor immunotherapy of advanced malignancies, in particular, antibodies directed against CTLA-4 and PD-1/PD-L1, the development of immune-related adverse events (irAEs) remains a constraint of this type of therapy. Although rarely fatal, the occurrence of irAEs may necessitate discontinuation of immunotherapy, as well as administration of corticosteroids or other immunosuppressive therapies that may not only compromise efficacy but also predispose for development of opportunistic infection. Clearly, retention of efficacy of immune checkpoint-targeted therapies with concurrent attenuation of immune-mediated toxicity represents a formidable challenge. In this context, the current brief review examines mechanistic relationships between these events, as well as recent insights into immunopathogenesis, and strategies which may contribute to resolving this issue. These sections are preceded by brief overviews of the discovery and functions of CTLA-4 and PD-1, as well as the chronology of the development of immunotherapeutic monoclonal antibodies which target these immune checkpoint inhibitors.

Immune-related adverse events (IrAEs) affecting the gastrointestinal (GI) tract and liver are among the most frequent and most severe inflammatory toxicities from contemporary immunotherapy. Inflammation of the colon and or small intestines (entero)colitis is the single most common GI IrAE and is an important cause of delay of discontinuation of immunotherapy. The severity of these GI IrAEs can range from manageable with symptomatic treatment alone to life-threatening complications, including perforation and liver failure. The frequency and severity of GI IrAEs is dependent on the specific immunotherapy given, with cytotoxic T lymphocyte antigen (CTLA)-4 blockade more likely to induce severe GI IrAEs than blockade of either programmed cell death protein 1 (PD-1) or PD-1 ligand (PD-L1), and combination therapy showing the highest rate of GI IrAEs, particularly in the liver. To date, we have minimal prospective data on the appropriate diagnosis and management of GI IrAEs, and recommendations are based largely on retrospective data and expert opinion. Although clinical diagnoses of GI IrAEs are common, biopsy is the gold standard for diagnosis of both immunotherapy-induced enterocolitis and hepatitis and can play an important role in excluding competing, though less common, diagnoses and ensuring optimal management. GI IrAEs typically respond to high-dose corticosteroids, though a significant fraction of patients requires secondary immune suppression. For colitis, both TNF-α blockade with infliximab and integrin inhibition with vedolizumab have proved highly effective in corticosteroid-refractory cases. Detailed guidelines have been published for the management of low-grade GI IrAEs. In the setting of more severe toxicities, involvement of a GI specialist is generally recommended. The purpose of this review is to survey the available literature and provide management recommendations focused on the GI specialist.

PROBLEM IDENTIFICATION. Hot flashes (HF) are common and bothersome in breast and prostate cancer and can adversely impact patients’ quality of life. The best approach to manage them is unclear. We sought to perform network meta-analyses (NMA) of the available evidence to compare interventions previously studied in the literature. LITERATURE SEARCH. A librarian searched Medline, Embase, and additional databases for randomized controlled trials (RCTs) evaluating the effects of one or more interventions for hot flashes in patients with a history of breast or prostate cancer. DATA EVALUATION. Outcomes of interest included changes in HF severity, HF frequency, quality of life, and harms. Two reviewers were involved in the phases of study selection, data collection and risk of bias appraisal. Pairwise meta-analyses and NMAs were performed where feasible, with narrative synthesis used where required. SYNTHESIS. 40 RCTs studying drugs, psychological interventions, natural health products and exercise were included. Most interventions were assessed in only one trial, typically versus inactive control. The outcomes of interest were not consistently available from the included studies, and NMAs were feasible for HF frequency and HF score. Findings from NMA for HF frequency suggested several therapies may offer benefits compared to no treatment, though little data suggested differences between active therapies. Findings from NMA for HF score were similar. For remaining outcomes including HF severity, QoL measures and harms, studies were summarized narratively due to limited availability of data. Limited evidence of clear benefits was found for the therapies assessed. IMPLICATIONS FOR RESEARCH. While many interventions may offer improvements for HFs versus no treatment, few data suggest important differences between therapies. Future research is needed to enrich available evidence for decision-making. REVIEW REGISTRATION #: CRD42015024286

Background Evidence-based practice (EBP) is a clinical decision-making approach that improves quality and outcomes in health care but is not yet standard in clinical settings. Objectives The purpose of this study was to determine EBP beliefs, knowledge, implementation strategy self-efficacy, and competencies among a national sample of oncology nurses. Methods Oncology nurses completed an online survey of EBP attributes and open-ended questions. Analyses were conducted on data collected from 893 participants from a range of healthcare organizations across a diverse geographic sample of the United States. Findings Respondents rated themselves competent to question clinical practice to improve quality care. Oncology nurses reported competency to question clinical practice but deficits in EBP knowledge and skills.

The development of rigorous, high-quality clinical guidelines increases the need for resources and skilled personnel within guideline-producing organizations. While collaboration between organizations provides a unique opportunity to pool resources and save time and effort, the collaboration presents its own unique challenges.To assess the perceived needs and current challenges of guideline producers worldwide related to guideline development and collaboration efforts.Survey questions were developed by the Guidelines International Network and the US GRADE Network, pilot-tested among attendees of a guideline development workshop, and disseminated electronically using convenience and snowball sampling methods.A total of 171 respondents representing 30 countries and more than 112 unique organizations were included in this analysis.The survey included free-response, multiple-choice, and seven-point Likert-scale questions. Questions assessed respondents' perceived value of guidelines, resource availability and needs, guideline development processes, and collaboration efforts of their organization.Time required to develop high-quality systematic reviews and guidelines was the most relevant need (median=7; IQR=5.5-7). In-house resources to conduct literature searches (median=4; IQR=3-6) and the resources to develop rigorous guidelines rapidly (median=4; IQR=2-5) were perceived as the least available resources. Difficulties reconciling differences in guideline methodology (median=6; IQR=4-7) and the time required to establish collaborative agreements (median=6; IQR=5-6) were the most relevant barriers to collaboration between organizations. Results also indicated a general need for improvement in conflict of interest (COI) disclosure policies.The survey identified organizational challenges in supporting rigorous guideline development, including the time, resources, and personnel required. Connecting guideline developers to existing databases of high-quality systematic reviews and the use of freely available online platforms may facilitate guideline development. Guideline-producing organizations may also consider allocating resources to hiring or training personnel with expertise in systematic review methodologies or utilizing resources more effectively by establishing collaborations with other organizations.

Managing pain can be challenging, especially in patients with serious illnesses and a history of substance use disorders. This article discusses the challenges of addressing pain in these patients and offers perspectives regarding their clinical management.

PROBLEM IDENTIFICATION A systematic review and meta-analysis was conducted to inform the development of national clinical practice guidelines on the management of cancer constipation. LITERATURE SEARCH PubMed®, Wiley Cochrane Library, and CINAHL® were searched for studies published from May 2009 to May 2019. DATA EVALUATION Two investigators independently reviewed and extracted data from eligible studies. The Cochrane Collaboration risk-of-bias tool was used, and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess the certainty of the evidence. SYNTHESIS For patients with cancer and opioid-induced constipation, moderate benefit was found for osmotic or stimulant laxatives; small benefit was found for methylnaltrexone, naldemedine, and electroacupuncture. For patients with cancer and non-opioid-related constipation, moderate benefit was found for naloxegol, prucalopride, lubiprostone, and linaclotide; trivial benefit was found for acupuncture. IMPLICATIONS FOR PRACTICE Effective strategies for managing opioid-induced and non-opioid-related constipation in patients with cancer include lifestyle, pharmacologic, and complementary approaches. SUPPLEMENTAL MATERIAL CAN BE FOUND ATNHTTPS //bit.ly/3c4yewT.

Problem identification Preventing and managing skin toxicities can minimize treatment disruptions and improve well-being. This systematic review aimed to evaluate the effectiveness of interventions for the prevention and management of cancer treatment-related skin toxicities. Literature search The authors systematically searched for comparative studies published before April 1, 2019. Study selection and appraisal were conducted by pairs of independent reviewers. Data evaluation The random-effects model was used to conduct meta-analysis when appropriate. Synthesis 39 studies (6,006 patients) were included; 16 of those provided data for meta-analysis. Prophylactic minocycline reduced the development of all-grade and grade 1 acneform rash in patients who received erlotinib. Prophylaxis with pyridoxine 400 mg in capecitabine-treated patients lowered the risk of grade 2 or 3 hand-foot syndrome. Several treatments for hand-foot skin reaction suggested benefit in heterogeneous studies. Scalp cooling significantly reduced the risk for severe hair loss or total alopecia associated with chemotherapy. Implications for research Certainty in the available evidence was limited for several interventions, suggesting the need for future research. Supplemental material can be found at https //onf.ons.org/supplementary-material-targeted-therapy-and-chemotherapy-associated-skin-toxicity-systematic-review.

Purpose Lymphedema is a chronic condition that may result from cancer-related surgery. The incidence of lymphedema varies greatly; however, patients remain at risk for life and may experience decreased quality of life and functional capacity. Providing recommendations for an evidence-based guideline for care of cancer treatment-related lymphedema will help to improve outcomes for patients with this chronic condition. Methodologic approach A panel of healthcare professionals with patient representation convened to develop a national clinical practice guideline on prospective surveillance, risk reduction, and conservative treatment of lymphedema. Systematic reviews of the literature were conducted and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology approach was used to assess the evidence. Findings The panel made multiple recommendations for patients who are at risk for or experiencing lymphedema. Implications for nursing Early diagnosis and treatment of lymphedema may mitigate symptoms. This evidence-based guideline supports patients, clinicians, and other healthcare professionals in clinical decision making. Supplementary material can be found at https //onf.ons.org/supplementary-material-ons-guidelines-cancer-treatment-related-lymphedema.

Problem identification Secondary lymphedema is a chronic condition that may result from cancer-related treatments. Evidence is emerging on prospective surveillance and risk reduction. Literature search Databases were systematically searched through April 1, 2019, for comparative studies evaluating interventions aiming to prevent lymphedema in patients with cancer. Data evaluation A random-effects model was used to perform meta-analysis, when appropriate. Synthesis A total of 26 studies (4,095 patients) were included, with 23 providing data sufficient for meta-analysis. Surveillance programs increased the likelihood of detecting lymphedema. Physiotherapy, exercise programs, and delayed exercise reduced the incidence of lymphedema. Implications for research Future research should standardize (a) evidence-based interventions to reduce the development of lymphedema and increase the likelihood of early detection and (b) outcome measures to build a body of evidence that leads to practice change. Supplemental material can be found at https //onf.ons.org/supplementary-material-systematic-review-cancer-treatment-related-lymphedema.

Background Management of cancer treatment-related skin toxicities can minimize treatment disruptions and improve patient well-being. Objectives This guideline aims to support patients and clinicians in decisions regarding management of cancer treatment-related skin toxicities. Methods A panel developed a guideline for management of cancer treatment-related skin toxicities using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) for certainty of evidence and the National Academies of Sciences, Engineering, and Medicine criteria for trustworthy guidelines. The Cochrane risk-of-bias tool assessed risk of bias. A quantitative or narrative synthesis of the evidence was completed. Results The panel issued seven conditional recommendations for epidermal growth factor receptor inhibitor rash, hand-foot skin reaction, hand-foot syndrome, and chemotherapy-induced alopecia. The panel suggested strategies for prevention and treatment for all toxicities except hand-foot syndrome, which only has a prevention recommendation. Implications for nursing Cancer treatment-related skin toxicities can significantly affect quality of life. Incorporation of these interventions into clinical care can improve patient outcomes. Supplementary material can be found at https //onf.ons.org/supplementary-material-ons-guidelines-cancer-treatment-related-skin-toxicity.

Cancer-related hot flashes are often a lasting and distressing side effect of hormone-blocking therapies that are most often experienced by women with breast cancer and men with prostate cancer treated with these therapies. Hot flashes have been defined as a sensation of heat that may be accompanied by facial flushing, perspiration, chills, heart palpitations, night sweats, and feelings of anxiety. The frequency and intensity of hot flashes can cause fatigue and sleep disturbances that diminish quality of life and reduce adherence with prescribed therapies that block estrogens or androgens. Hot flashes are reported to be significantly more frequent and severe in women treated for breast cancer than in women undergoing natural menopause. They also commonly occur in men treated for prostate cancer with surgical or chemical castration to block the synthesis of androgens that can fuel cancer growth.

Immune checkpoint inhibitors (ICIs) have emerged as the newest pillar of cancer treatment. Immune-mediated toxicities, stemming from increased activity within the T cell lineage, range from asymptomatic or mild complications to those that are fulminant and potentially fatal. Although they are of variable occurrence, cardiovascular, rheumatic, and renal immune-mediated toxicities are among the most serious of these adverse events. We present MASCC recommendations with respect to the workup and management of cardiovascular, rheumatic, and renal immune-mediated toxicities with a focus on presentations that require treatment with immunomodulating agents.

The immune checkpoints associated with the CTLA-4 and PD-1 pathways are critical modulators of immune activation. These pathways dampen the immune response by providing brakes on activated T cells, thereby ensuring more uniform and controlled immune reactions and avoiding immune hyper-responsiveness and autoimmunity. Cancer cells often exploit these regulatory controls through a variety of immune subversion mechanisms, which facilitate immune escape and tumor survival. Immune checkpoint inhibitors (ICI) effectively block negative regulatory signals, thereby augmenting immune attack and tumor killing. This process is a double-edged sword in which release of regulatory controls is felt to be responsible for both the therapeutic efficacy of ICI therapy and the driver of immune-related adverse events (IrAEs). These adverse immune reactions are common, typically low-grade and may affect virtually every organ system. In the early clinical trials, lung IrAEs were rarely described. However, with ever-expanding clinical applications and more complex ICI-containing regimens, lung events, in particular, pneumonitis, have become increasingly recognized. ICI-related lung injury is clinically distinct from other types of lung toxicity and may lead to death in advanced stage disease. Thus, knowledge regarding the key characteristics and optimal treatment of lung-IrAEs is critical to good outcomes. This review provides an overview of lung-IrAEs, including risk factors and epidemiology, as well as clinical, radiologic, and histopathologic features of ICI-related lung injury. Management principles for ICI-related lung injury, including current consensus on steroid refractory pneumonitis and the use of other immune modulating agents in this setting are also highlighted.

PURPOSE: The purpose of this study was to measure the feasibility of an alternative and augmentative communication (AAC) application and an iPad (a customized tablet) to facilitate communication in post-operative patients with head and neck cancer. DESIGN: A prospective feasibility study. METHODS: The study was conducted in the main postanesthesia care unit at an urban comprehensive cancer center in the northeast United States between January 2014 and September 2014. The participants included patients with head and neck cancer who underwent surgery that resulted in altered communication. Patient questionnaires were developed and administered to measure feasibility and patient satisfaction at different time points (preoperative, postoperative, one to four days postoperatively). FINDINGS: Of 38 patients consented to the study, 25 (66%) were able to use the customized tablet. Of these 25 patients, 15 (60%) were satisfied or somewhat satisfied with it. In addition, 84% found the customized tablet to be very or somewhat helpful for communication following surgery. CONCLUSIONS: Patients were satisfied with the customized tablet and the study found that using technology such as this was feasible in the immediate postoperative period.

Background Chronic diseases, such as opioid use disorder (OUD) require a multifaceted scientific approach to address their evolving complexity. The Council for the Advancement of Nursing Science's (Council) four nursing science priority areas (precision health; global health, determinants of health, and big data/data analytics) were established to provide a framework to address current complex health problems. Purpose To examine OUD research through the nursing science priority areas and evaluate the appropriateness of the priority areas as a framework for research on complex health conditions. Method OUD was used as an exemplar to explore the relevance of the nursing science priorities for future research. Findings Research in the four priority areas is advancing knowledge in OUD identification, prevention, and treatment. Intersection of OUD research population focus and methodological approach was identified among the priority areas. Discussion The Council priorities provide a relevant framework for nurse scientists to address complex health problems like OUD.

320 Background: The increase in patients receiving oral oncolytics requires oncology health care professionals to have processes and interventions that support patient adherence. Because adherence to oral oncolytics is a priority for achieving optimal outcomes, the ASCO QOPI Standards emphasize the need to assess for adherence at meaningful intervals as well as implement interventions to promote adherence. Technology-based interventions have the potential to assess and support adherence. The objective of this review is to evaluate the overall effect of any technology-based intervention, as well as compare the use of interactive technology rather than non-interactive technology to improve oral oncolytic adherence. This review will serve as the evidence base for a clinical practice guideline on oral oncolytic adherence. Methods: A medical librarian searched EMBASE, PubMed, and CINAHL for comparative studies published in English from January 2000 to May 2021. Two reviewers screened titles and abstracts, and eligible full text articles independently and in duplicate using Covidence. When possible, quantitative findings were pooled in a meta-analysis. Risk of bias assessment for randomized controlled trials was done using the Cochrane Collaboration risk-of-bias 2.0 tool and for observational studies, the ROBINS-I instrument was used. The certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Results: Out of 663 studies, we identified 14 as eligible for analysis. Of the six RCTs (n = 737) that compared any technological intervention to no intervention, there was some heterogeneity across interventions (e.g., text messaging, mobile app, computer program) and reported outcome measures for adherence, including adherence rates, relative dose intensity (RDI), and number of weeks adherent. Patients using any technology rather than no technology may have higher adherence rates (MD: 8.81; 95% CI: 3.82, 13.81); however, there may be little effect on RDI (MD: -0.01; 95% CI: -0.04, 0.02) and number of weeks adherent (MD: -0.70; 95% CI: -1.96, 0.56), respectively. One RCT (n = 444) reported on adolescents receiving interactive and non-interactive interventions. There may be little effect on adherence rates among patients receiving interactive technology interventions rather than non-interactive education intervention (MD: 1.5; 95% CI, −0.2, 3.2). Conclusions: Better systems of oral oncolytic care are needed to support patients and their caregivers. Technology-based interventions may improve medication adherence in cancer patients on oral oncolytics; however, we are uncertain about the impact on other measure of adherence or the superiority of interactive rather than non-interactive technology interventions. Due to inconsistency in the evidence, additional research in this area is recommended.

236 Background: Older adults are more likely to be diagnosed with cancer than their younger counterparts. Because the underlying health status of older adults with cancer is generally heterogeneous, geriatric assessment (GA) is helpful for uncovering age-related vulnerabilities and guiding subsequent care planning. GA provides multidimensional, multidisciplinary evaluations of pertinent health domains. When used to evaluate an older adult with cancer prior to initiating therapy, GA and screening tools can help oncologists differentiate between fit and frail patients and tailor their treatment accordingly. Methods: The Association of Community Cancer Centers (ACCC) conducted a 4-round Delphi method to achieve expert consensus (≥75%) related to 9 domains of geriatric oncology care from a multidisciplinary perspective. A survey was conducted with 70 international clinicians working in geriatric oncology to assess perspectives on guideline-recommended GA tools in clinical practice. Facilitator led focus groups were conducted to review the results in a large group format and come to consensus. Aggregated results were shared back with the group to ensure effective capture of group discussion regarding validated clinical practice tools to include as resources in the gap assessment instrument. Results: A 32 question geriatric oncology gap assessment was developed in an online survey platform. This tool was beta tested by 30 individuals at cancer programs of various types and regions across the US. A final version was published and made accessible for multidisciplinary teams to self-assess care delivery for older adults with cancer in 9 domains: Functional Status; Cognition; Comorbidities; Decision Making: Screening, Life Expectancy, Chemo Toxicity; Pharmacy/Medication Management; Psychological Health; Nutrition; Patient Goals and Needs; and Communication and Workforce Training. Within each domain, respondents select the level (see Table) that most closely represents the practice(s) at their institution. A personalized report is generated. Sample Question. Conclusions: The ACCC geriatric oncology gap assessment offers cancer programs a validated way to evaluate care delivery for older adults with cancer. To optimize workflow, cancer programs should consider utilizing gap assessment results to develop and advance scalable quality improvement programs at their institution, taking into consideration resource level and infrastructure.[Table: see text]

Immunotherapy research provides opportunities for nurse scientists and researchers to be at the forefront of the changing landscape of cancer treatment. As these therapies continue to develop, current initiatives will seek to support nurses in clinical practice who must provide safe, evidence-based care and education to patients and their families. This article explores the current state of immunotherapy research and the ways in which continued research can help to advance nursing education and practice.

As cancer treatment shifts to a combination of oral and intravenous agents for systemic treatment, health care professionals must adapt with practice changes aimed at supporting patients and optimizing adherence. Moving toward a shared decision-making model or a personal systems approach is a potential mechanism to minimize barriers and enhance facilitators to oral treatment adherence. Additional research is needed to understand what works for patients and how health care providers can change systems and care strategies to support patients with the ultimate goal of improved patient care and outcomes.

Multisite research is an important strategy to strengthen the external validity of nursing science (O'Mara, BauerWu, Berry, & Lillington, 2007). In contrast to single-site studies, research projects conducted with multiple sites offer potentially larger, more diverse participant samples and reduce the likelihood of idiosyncratic research findings. Conversely, multisite studies are more complicated to conduct and administer. New complexities also arise when research participants are staff, as opposed to patients or clients.Workplace intervention studies are increasing, due in part to growing awareness that improved worker health and safety have downstream societal benefits (Anger etal., 2015). Specifically, the NationalInstitute for Occupational Safety and Health (NIOSH) has launched the Total Worker Health initiative to respond to this challenge (NIOSH, 2016; Weisfeld, Lustig, & Board of Health Sciences Policy, 2014). Healthy workers are associated with lower turnover, improved economic productivity, and enhanced personal well-being. Due to labor shortages, high acuity, long shifts, and physical demands, NIOSH has identified healthcare workers as a vulnerable labor sector for intervention (NIOSH, 2013). For the past 10 years, our interdisciplinary team has documented the specific concerns of oncology nurses employed in ambulatory oncology settings. These nurses face an unusual occupational threat of hazardous drug exposure given the high patient volume, the explicit emphasis on chemotherapy treatment, and associated continuous risks of exposure.Our team documented that 18% of surveyed ambulatory oncology nurses experienced an unplanned hazardous drug spill in the preceding 6 months (Friese et al., 2014). Hazardous drug exposure is correlated with substantial short- and long-term health effects, such as nausea, vomiting, airway irritation, reproductive problems, and rare cancers (NIOSH, 2004). Despite 30 years of data to support the need for increased vigilance when handling hazardous drugs, surprisingly few nurses wear personal protective equipment as recommended (Connor & McDiarmid, 2006; Polovich & Clark, 2012). Except for the current project, only one published study examined an educational intervention for nurses, conducted in one Malaysian hospital (Keat, Sooaid, Yun, & Sriraman, 2013). Thus, we lack sufficient evidence on how to improve nurses' use of personal protective equipment when handling hazardous drugs.The Drug Exposure Feedback and Education for Nurses' Safety (DEFENS) study is a 4-year, multisite cluster randomized controlled trial (Friese, MendelsohnVictor, et al., 2015). The study compares one-time static educational information about hazardous drug exposure prevention to quarterly feedback on study results, coupled with tailored messages designed to reduce barriers to protective equipment use. In planning for the project, we reviewed the sparse literature that describes multisite research project management with registered nurse employees as participants. In the current article, we review successful study implementation strategies and identify important considerations for future research projects that plan to incorporate nurses as participants.ApproachThe DEFENS study is a cluster randomized controlled trial. Nurses who work 16 hr a week or more in ambulatory infusion within 12 large cancer centers in the United States were invited to participate. Full details may be found in the published protocol paper (Friese, Mendelsohn-Victor, et al., 2015) or in the ClinicalTrials.gov registry (National Institutes of Health [NIH], 2016a). Guided by extant models of health behavior and risk reduction, we hypothesized that one-time educational content is insufficient to improve nurses' use of personal protective equipment when handling hazardous drugs (McCullagh, Ronis, & Lusk, 2010). Rather, we compared static educational content (control intervention) to quarterly feedback about data gleaned from our study, coupled with video messages tailored to participants' reported barriers to protective equipment use (experimental intervention). …

Changes are underway at the Oncology Nursing Society to align resources so that scientists have the support needed to generate new knowledge and clinicians have access to tools needed to use evidence-based interventions that can speed the translation of research to transform cancer care.

Background As the population of older adults continues to increase, the healthcare system must adapt to respond to their unique and complicated health needs. More than half of all patients diagnosed with cancer in America are aged 65 years or older. The appropriate care for older adult patients with cancer requires a holistic approach with careful coordination of interprofessional providers. Objectives This article aims to describe the components of the comprehensive geriatric assessment, summarize the importance of exercise in older adults, discuss the harms of polypharmacy, and evaluate the initiatives to improve geriatric nursing education. Methods The literature was reviewed and summarized to provide information on comprehensive geriatric assessment, exercise, polypharmacy, and geriatric nursing education. Findings Numerous assessment tools can help guide the care of older adult patients with cancer. Because many nurses have little formal geriatric-specific training, there is a growing need for targeted education to ensure best practices.

Oral anticancer medication (OAM) use has been steadily increasing, leading to several patient benefits. A notable challenge for nurses is accurate monitoring of patient OAM regimens because nonadherence is associated with poor health outcomes and decreased survival. Currently, no gold standard measure of OAM adherence exists. The authors conducted a systematic review of the association between objective and patient-reported measures of OAM adherence. .A systematic electronic literature search was conducted using PubMed, EMBASE, Scopus, PsycINFO®, Cochrane Library, Web of Science, and CINAHL® databases through November 2014. .Articles were independently reviewed to determine whether they included an original characterization of the level of association between objective and patient-reported measures of OAM adherence. .From a total of 11,135 articles retrieved, eight studies met inclusion criteria. Objective adherence was primarily assessed using pill counts or Medication Event Monitoring System (MEMSCap™). Patient-reported adherence was most commonly assessed using study-specific questionnaires. Significant positive correlations were observed between objective and patient-reported adherence across most studies, with three studies reporting higher rates of adherence via patient reporting. .Despite variation in the OAMs and measures used, patient-reported adherence rates were equal to or higher than objective adherence measures across studies. Social desirability bias may be a concern; however, given the significant concordance observed, using patient-reported methods in future studies of OAM adherence may be justified. .This review provides evidence to support nursing use of patient-reported measures to accurately monitor OAM adherence and potentially improve the quality of patient-provider communication.

Nurses in clinical settings in which evidence-based, individualized care is expected are often the best resource to identify important clinical questions and gaps in practice. These nurses are frequently challenged by a lack of resources to fully develop their questions and identify the most appropriate methods to answer them. A strategic and ongoing partnership between medical library services and nursing can support nurses as they embark on the process of answering these questions and, ultimately, improving patient care and clinical outcomes

Background Animal-facilitated therapy (AFT) is a complementary medicine intervention. To the authors' knowledge, no study has investigated the benefits of an AFT program in an adult surgical oncology setting. Objectives The purpose of this study is to assess the effects of an AFT program on patients and staff on a surgical oncology unit. Methods A quasiexperimental design was used for the patient group, and a pre-/post-test design was used for the staff group. The intervention involved the AFT program being fully integrated on a surgical inpatient unit. Outcomes included patient-reported symptoms and quality-of-life (QOL) outcomes for patients, as well as professional QOL for staff. Findings QOL indicators improved for all patients, and the level of energy at follow-up was significantly higher in the AFT group after adjusting for baseline. For staff, compassion satisfaction was high and burnout was low.

Purpose To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events in patients treated with immune checkpoint inhibitor (ICPi) therapy. Methods A multidisciplinary, multi-organizational panel of experts in medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, urology, neurology, hematology, emergency medicine, nursing, trialist, and advocacy was convened to develop the clinical practice guideline. Guideline development involved a systematic review of the literature and an informal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, randomized controlled trials, and case series published from 2000 through 2017. Results The systematic review identified 204 eligible publications. Much of the evidence consisted of systematic reviews of observational data, consensus guidelines, case series, and case reports. Due to the paucity of high-quality evidence on management of immune-related adverse events, recommendations are based on expert consensus. Recommendations Recommendations for specific organ system–based toxicity diagnosis and management are presented. While management varies according to organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, with the exception of some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert to grade 1 or less. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids (prednisone 1 to 2 mg/kg/d or methylprednisolone 1 to 2 mg/kg/d). Corticosteroids should be tapered over the course of at least 4 to 6 weeks. Some refractory cases may require infliximab or other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, with the exception of endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .

As cancer treatment shifts to a combination of oral and intravenous agents for systemic treatment, health care professionals must adapt with practice changes aimed at supporting patients and optimizing adherence. Moving toward a shared decision-making model or a personal systems approach is a potential mechanism to minimize barriers and enhance facilitators to oral treatment adherence. Additional research is needed to understand what works for patients and how health care providers can change systems and care strategies to support patients with the ultimate goal of improved patient care and outcomes.

For patients with head and neck cancer, altered communication is a frequently occurring and highly upsetting issue that has been associated with psychological distress, fear, and anger among those with temporary or permanent speech impairment postsurgery. Many postoperative patients express that the most terrifying situation is to wake up from surgery and not be able to speak. Mobile devices have become part of everyday life, and augmentative and alternative communication mobile applications have the potential to enhance the healthcare journey of the patient and provider.

Intrusive thoughts could impair smoking cessation or cause relapse to the extent that the thoughts are stimuli for smoking. This is a secondary analysis of data provided by 61 participants attempting to quit smoking. Participants used a hand-held computer to capture, in real time, the experience of quitting smoking. Intrusive thoughts related to smoking were assessed and participants completed assessments when they had an urge to smoke or after they slipped. The outcomes included were proximal measures of smoking cessation: number of slips, number of resisted temptations to smoke, and urge levels of during cessation. Independent variables were smoking stimuli, intrusive thoughts and depressive symptoms. Data were analyzed using multilevel modeling. Intrusive thoughts were significantly and positively related to each cessation outcome (slips, resists, urge levels). Smoking stimuli were differentially related to outcomes; cigarette availability was related to slips; being in usual smoking situations was ass...

Purpose/objective To explore patterns of symptoms before and after surgery for cancer of the esophagus. Design Longitudinal, descriptive study. Setting An urban comprehensive cancer center in the northeastern United States. Sample 218 patients with cancer of the esophagus undergoing esophagectomy. Methods Symptoms were assessed by self-report before surgery, at the first postoperative visit, and at 6 and 12 months postsurgery. Main research variables Symptoms and demographic and clinical variables, including stage, treatment, gender, and comorbidities. Findings Patients with esophageal cancer reported numerous symptoms before and after esophagectomy. Several patterns of symptoms were identified. General cancer symptoms (e.g., pain, cough, shortness of breath, weight loss) were reported as worse after surgery but recovered to baseline by one year. A second pattern of esophageal-specific symptoms (feeling full too quickly, feeling bloated, nausea, and diarrhea) worsened after surgery and did not recover to baseline by one year. Reflux was the only symptom that did not worsen after surgery but did worsen significantly during the first year of recovery. Conclusions Patients with esophageal cancer experienced multiple prolonged symptoms following surgical treatment for their disease. General cancer symptoms resolved by one year post-treatment, whereas esophageal-specific symptoms worsened after surgery and did not recover to baseline. Implications for nursing Identification of symptom patterns preoperatively and during recovery can assist nurses in developing intervention protocols to minimize long-term complications for patients with esophageal cancer. Knowledge translation Patients with esophageal cancer are at risk for multiple prolonged symptoms following surgery. Symptom assessment should occur often after surgery and include a broad range of symptoms.

Objective We sought to determine whether an acupuncture technique specially developed for a surgical oncology population (intervention) reduces pain or analgesic use after thoracotomy compared with a sham acupuncture technique (control). Methods One hundred sixty-two patients with cancer undergoing thoracotomy were randomized to group A (preoperative implantation of small intradermal needles that were retained for 4 weeks) or group B (preoperative placement of sham needles at the same schedule). The numeric rating scale of pain and total opioid use was evaluated during the in-patient stay, and the Brief Pain Inventory and Medication Quantification Scale were evaluated after discharge up to 3 months after the operation. Results The principal analysis, a comparison of Brief Pain Inventory pain intensity scores at the 30-day follow-up, showed no significant difference between the intervention and control groups. Pain scores were marginally higher in the intervention group (0.05; 95% confidence interval, 0.74 to −0.64; P = .9). There were also no statistically significant differences between groups for secondary end points, including chronic pain assessments at 60 and 90 days, in-patient pain, and medication use in the hospital and after discharge. Conclusion A special acupuncture technique, as provided in this study, did not reduce pain or use of pain medication after thoracotomy more than a sham technique.

7123 Background: Measuring DNA in plasma using quantitative RT-PCR is a promising method for surveillance of NSCLC. This strategy has the potential to assess response more accurately or quickly than radiologic tests, or to confirm the success of surgical resection and select patients for adjuvant therapy. Methylated genes may be more specific than total DNA for the presence of cancer. Methods: We are conducting two prospective trials measuring total DNA, and 10 commonly hypermethylated genes in the plasma of NSCLC patients before and after therapy. For patients undergoing surgery, plasma samples are collected before, and at three timepoints after surgery (3–8 d, 2–5 w, 2–4 m). For patients on chemotherapy, collections are before, and coincident with up to 3 radiologic response assessments. DNA is extracted from a fixed volume of plasma, and measured using quantitative PCR of the β-Actin gene. After treating DNA with sodium metabisulfite, methylation-specific RT-PCR is performed to amplify the promoter region of APC, p16, MGMT, GSTP1, DAPK, CDH1, RASSF1A, WIF-1, SOCS-3, METH-2, assuming the promoter is fully methylated. Gene levels are normalized to β-Actin in modified DNA. Results: To date, plasma analysis has been completed on 50 patients with advanced NSCLC undergoing chemotherapy (320 planned), and 60 patients with early-stage NSCLC undergoing surgery (400 planned). Pretreatment levels of total DNA are higher in metastatic NSCLC (median 9.2, range 2.2–1020 ng/ml) compared to early-stage (median 3.6, range 0–1280 ng/ml), p < 0.001 by Wilcoxon rank sum test. At least one methylated gene is detectable in pretreatment plasma in 36% of patients with metastatic NSCLC, and 20% of patients with early-stage NSCLC. Conclusions: Methylated genes are rarely found in the pre-treatment plasma of NSCLC patients in this experiment, despite testing a panel of 10 genes. Plasma total DNA levels correlate with NSCLC stage. Correlation of baseline levels of total DNA, and temporal trends during treatment, to overall survival and radiologic response are planned. Supported by R01-CA092315. [Table: see text]