Constituent member of ANA

The mission of the Delaware Nurses Association is to improve healthcare in Delaware by the advancement of nursing.Quarterly publication direct mailed to approximately 12,000 RNs and LPNs in Delaware.

Volume 44 • Issue 4 November, December 2019, January 2020

ReporterThe Role of Smoking Cessationin Lung Screening Navigation

Page 5

Nurse Navigation: Improving a Patient’s Experience and Outcome

Page 7Trina M. Turner, MSN, RN-BC, LNC

Ginny Pugh, BSN, RN, OCN

current resident or

Presort StandardUS Postage

PAIDPermit #14

Princeton, MN55371

InsideDNA

REPORTER

Executive Director’s ColumnGuest Editor

Nora Katurakes earned her BSN from the University of Delaware and her MSN from the University of Texas Health Science Center – Houston. She is a Certified Oncology Nurse. Nora worked as the manager of the Community Health Outreach and Education Program at the Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System for over 20 years. Previously has worked in oncology at MD Anderson, National Institutes of Health, Visiting Nurse Association and Salick HealthCare. She is currently a manager for the Community Health Outreach and Education program at Christiana Care and serves on the Practice Council. She is involved in community work including Co-chair of the Wilmington Health Planning Council, member of the Early Detection and Prevention Committee for the Delaware Cancer Consortium and member of the American Cancer Society Leadership Council. Nora can be reached by email at nkaturakes@christianacare.org or her office at (302) 623-4628

Nora C. Katurakes

Sarah Carmody

Lung Cancer in Delaware: Nurses Serving Together

Nora C. Katurakes, MSN, RN, OCN®

Since 2015 the challenge was to develop and implement a statewide lung cancer screening program based on the United States Preventive Task Force (USPSTF) recommendations. Delaware’s citizens continue to be impacted by lung cancer. The recent incidence and mortality report shows little change for men and women. This edition of the DNA Reporter was the idea of several oncology nurses who have watched this disease take many loved ones, from our family and friends. Because of the importance and the many aspects of lung health and cancer, oncology nurses took action and coordinated

Guest Editor continued on page 2

DNA is a nurse advocacy organization. Its legislative mission is to strengthen the voice of nursing through legislative activities and to establish working and collaborative relationships with legislators and key stakeholders. Throughout the summer, DNA has been busy working to support this mission by attending events that provide information on pending healthcare and nursing issues as well as bring visibility to the association. DNA attended: ANA Membership Assembly, bill signings for House Bill 58 – Delaware Nursing Incentive Program and House Bill 79 – Default Beverages in Children’s Meals in Restaurants, Future of Nursing Townhall Meeting, ANA Lobbyist Meeting, DHSS Drug Overdose Mortality Survey Report meeting, and Senator Coons’ Addressing Delaware’s Opioid Crisis event.

Information sharing from these events as well as determining the DNA legislative agenda are done at the DNA Advocacy Committee meetings. Advocacy is about getting involved, sharing expertise, and engaging stakeholders to make a change in bettering a position or improving a situation. The word ‘advocacy’ comes from the Latin ‘advocare’ and literally means ‘to call out for support’. DNA calls out to all its members to get involved in this important work.

The Advocacy Committee meetings are open to all DNA members and welcome the sharing of ideas and expertise. Meetings are generally held the third Monday of the month in the DNA office. Though the General Assembly is not in session until January, there is still work to be done in planning the DNA legislative agenda and events. One event that is in the works is a DNA bus trip to Washington DC to attend the ANA Hill Day. This is a great opportunity to meet nurses from around the country and to join them in bringing the nursing voice to our nation’s Capitol. This event will take place in the middle of June 2020. The final date has yet to be announced by ANA. Please be sure to check the DNA website for meeting and event dates.

Finally, DNA has worked with Delaware Today magazine to improve the Top Nurse program. Explanation of the voting process, category descriptions and voting can be done on the DNA website. If you have any questions or comments, please send them to contactdna@denurses.org. This program is not limited to DNA members and is also open to licensed practical nurses. Please take a few minutes to vote for a nurse colleague that represents excellence in nursing.

President’s Message . . . . . . . . . . . . . . . . . . . . . 2DNA in Action . . . . . . . . . . . . . . . . . . . . . . . . . . 3Lung Cancer Screening: Shared Decision Making Issues? . . . . . . . . . . 4The Role of Smoking Cessation in Lung Screening Navigation . . . . . . . . . . . . 5How Health Care Providers Can Address E-Cigarette Use . . . . . . . . . . . . . . . . . . . . . . . 6Nurse Navigation: Improving a Patient’s Experience and Outcome . . . . . . . . . . . . . . . . 7

Lung Cancer and Nursing Research Coordinators – What’s The Connection? . . . . 8Immunotherapy and Lung Cancer . . . . . . . . . . 9Supportive and Palliative Care in Lung Cancer . . . . . . . . . . . . . . . . . 9Delaware Today Top Nurse Nominations . . . 10LPN Membership Activation Form . . . . . . . . 10DNA Membership Activation Form . . . . . . . 11Welcome New and Returning Members . . . . 11

The Official Publication of the Delaware Nurses Association

Page 2 • DNA Reporter November, December 2019, January 2020

I will be brief to conserve space for this content-packed edition of the Reporter. My thanks to our editors and all of our contributors.

This is a reminder of our redoubled efforts to increase DNA’s focus upon advocacy. Please be on the look-out for some new and interesting endeavors and initiatives that our Advocacy Committee has in store for you this fall and into the coming year.

A heartfelt thank you to the folks at Delaware Today magazine for working with DNA to improve the selection and recognition of Delaware’s top nurses. We expect that the planned changes will greatly improve this program. When the time comes please participate by nominating your favorite top nurses!

Congratulations to Penny Short, RN on her ascension to President of Nanticoke Hospital. It is quite impressive to see an RN in this position in one of Delaware’s seven acute-care hospitals.

Lastly, I encourage all of you to consider becoming more active in DNA. Opportunities abound for participation especially in the areas of advocacy and educational programs. As with any volunteer organization, participation waxes and wanes but the key to sustainability is a constant influx of new people with new ideas! Please come to the meetings and programs and please encourage your colleagues to join. We are all stronger together!

Thank you.

OFFICIAL PUBLICATIONof the

Delaware Nurses Association

4765 Ogletown-Stanton Road, Suite L10Newark, DE 19713

Phone: 302-733-5880Web: http://www.denurses.org

The DNA Reporter, (ISSN-0418-5412) is published quarterly every February, May, August and November by the Arthur L. Davis Publishing Agency, Inc., for the Delaware Nurses Association, a constituent member association of the American Nurses Association.

EXECUTIVE COMMITTEE

President Past PresidentGary W. Alderson, Leslie Verucci, RN, MSN, RN, Esq. CNS, CRNP-A, APRN-BC

Treasurer SecretaryJon M. Leeking, Christopher E. Otto, MSN, RN BSN, RN, CHFN, PCCN, CCRN

COMMITTEE CHAIRS

Continuing Education CommitteeKathleen Neal, PhD, RN on Nomination Felisha A. Alderson, Professional Development MSN, RN, CRRN

Sandra Nolan, PhD, RN Terry Towne, MSN, RN-BC, NE-BC

AdvocacyMembers of the Board of Directors

CommunicationsWilliam T. Campbell, Ed.D, RN

Karen Panunto, Ed.D, MSN, APRN

Executive DirectorSarah J. Carmody, MBA

ORGANIZATIONAL AFFILIATES

Oncology Nursing Society-Delaware Diamond Chaptercommunities.ons.org/delawarediamond/chapterleadership

Delaware Organization of Nurse Leaderswww.delawareone.org

Subscription to the DNA Reporter may be purchased for $20 per year, $30 per year for foreign addresses.

For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, sales@aldpub.com. DNA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.

Acceptance of advertising does not imply endorsement or approval by the Delaware Nurses Association of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. DNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of DNA or those of the national or local associations.

Managing EditorsWilliam T. Campbell, Ed.D, RN

Karen Panunto, Ed.D, MSN, APRN

The DNA Reporter welcomes unsolicited manuscripts by DNA members. Articles are submitted for the exclusive use of The DNA Reporter. All submitted articles must be original, not having been published before, and not under consideration for publication elsewhere. Submissions will be acknowledged by e-mail or a self-addressed stamped envelope provided by the author. All articles require a cover letter requesting consideration for publication. Articles can be submitted electronically by e-mail to Sarah J. Carmody, MBA @ sarah@denurses.org.

Each article should be prefaced with the title, author(s) names, educational degrees, certification or other licenses, current position, and how the position or personal experiences relate to the topic of the article. Include affiliations. Manuscripts should not exceed five (5) typewritten pages and include APA format. Also include the author’s mailing address, telephone number where messages may be left, and fax number. Authors are responsible for obtaining permission to use any copyrighted material; in the case of an institution, permission must be obtained from the administrator in writing before publication. All articles will be peer-reviewed and edited as necessary for content, style, clarity, grammar and spelling. While student submissions are greatly sought and appreciated, no articles will be accepted for the sole purpose of fulfilling any course requirements. It is the policy of DNA Reporter not to provide monetary compensation for articles.

ReporterPresident’s Message

Gary W. Alderson

this edition to share with other nurses. They intentionally wanted this to be a themed edition during November which is traditionally Lung Cancer Awareness Month. This theme is meant to draw attention during Lung Cancer Awareness Month and to highlight the expertise of the statewide nurses and providers who are delivering care across the lung health and cancer continuum. By sharing information in the areas of prevention, lung screening, care management, treatment, clinical trials and nurse navigation we will inform and educate our nurses statewide and bring more awareness to this cancer. Included in this edition are resources for access to programs such as the Delaware Quitline for smoking cessation, the Lung cancer screening programs statewide, the Screening for Life Program, the Delaware Cancer Treatment program, how to find clinical trials and the emerging role of immunotherapy. A dynamic speaker at a recent conference stated that if Delaware were to focus on the 30% mortality from lung cancer deaths it would impact the overall cancer ranking and further drop Delaware’s position in the rankings. As I began my career here in Delaware, we ranked third in the nation for cancer deaths. In twenty years, Delaware has dropped to 16 and recently to 18. Can you imagine a community with no lung cancer? Or more individuals who are living cured of lung cancer because it was found early? Or where new treatments like immunotherapy made a difference and clinical trials advanced the treatment for lung cancer? I hope that this edition energizes you to use this information for your family, friends and in your workplace. Let’s change the face of Lung Cancer in Delaware. It is time to end lung cancer. I have heard it said… if any state can do it… Delaware can.

Guest Editor continued from page 1

Did you know the DNA Reporter goes to all registered nurses in

Delaware for free?

Arthur L. Davis Publishing does a great job of contacting advertisers, who support the publication of our newsletter. Without Arthur L. Davis Publishing and advertising support, DNA would not be able to provide the newsletter to all the nurses in Delaware.

Now that you know that, did you know receiving the DNA Reporter does not automatically provide membership to

the Delaware Nurses Association?

DNA needs you! The Delaware Nurses Association works for the nursing profession as a whole in Delaware. Without the financial and volunteer support of our members, our work would not be possible. Even if you cannot give your time, your membership dollars work for you and your profession both at the state and national levels. The DNA works hard to bring the voice of nursing to Legislative Hall, advocate for the profession on regulatory committees, protect the nurse practice act, and provide educational programs that support your required continuing nursing education.

At the national level, the American Nurses Association lobbies, advocates and educates about the nursing profession to national legislators/regulators, supports continuing education and provides a unified nationwide network for the voice of nurses.

Now is the time! Now is the time to join your state nurses

association! Visit www.denurses.org to join or

call (302) 733-5880.

Did ?YouKnow

LPNs or RNs(full time and part time positions available)

Want Less Pressure? More Flexible Hours?

We offer competitive wages in a Christian environment.

Resume can be emailed to bekatroyer@aol.com or faxed to 302.349.5009

Country Rest Home12046 Sunset Lane, Greenwood, DE 19950

Phone: 302.349.4114

November, December 2019, January 2020 DNA Reporter • Page 3

ANA Membership Assembly

DNA in ActionFuture of Nursing Town Hall Meeting

House Bill 79 Signing

Page 4 • DNA Reporter November, December 2019, January 2020

Rosemarie A. Tucci, MSN, RN, AOCN ®

Rosemarie A. Tucci, earned her BSN from the University of Delaware, her MSN from Widener University and her postgraduate certificate in Nursing Administration from Villanova University. She is an Advanced Certified Oncology Nurse through Oncology Nursing Society. Ro has worked in a variety of management and educational positions with Main Line Health for the last 31 years. Prior, she worked at Delaware Hospice and Crozer-Chester Medical Center. She is currently the program coordinator for the Main Line Health Pulmonary Nodule program. She has authored numerous articles in a variety of oncology related topics, including quality improvements in pain control, clinical pathways of care, pulmonary navigation and issues in ethics. Ro can be reached by email at TucciRo@mhs.org or her office at (484) 476-2681.

Rosemarie A. Tucci

Lung Cancer Screening: Shared Decision Making Issues?

Getting a low-dose CT scan done for lung cancer screening is important, but how important and from whose perspective can be an issue. Evidence from the National Lung Screening Trial (NSLT) showed that a low-dose chest CT (LDCT) performed annually among high-risk patients for lung cancer screening found lung cancers earlier and resulted in a 20% reduction in mortality secondary to lung cancer. High-risk has been defined as patients aged 55-74 years, current or former smokers who quit within 15 years and has a 30+ pack-year history of smoking who are asymptomatic (Aberle et al., 2011).

Shared decision making is defined as a thorough discussion of benefits and harms that should happen between a physician/nurse practitioner and their patients with regards to any test or procedure. In the case of the Lung Screening CT scan, some discussion items should include the patient’s level of risk for the development of lung cancer, what this test entails, an explanation of the options if the scan is not done, pros and cons of what might be found by the scan (including false positive and negative findings) and methods that might be required to manage them and the patient’s willingness to undergo additional scans and treatments and above all – did the patient understand what was

discussed! This is so important that the Centers for Medicare and Medicaid Services (CMS) now requires documentation of this decision-making discussion and is willing to pay for a separate appointment for this payment to take place. Additionally, clinicians should query the patient on smoking cessation if they are current smokers and have information available on support systems for quitting (cms.gov/Medicare-coverage-database) If this is what is being questioned, it is the Medicare website for payment coverage. All of this information must be documented in the patient record for CMS to cover the cost of the scans. While this is not mandatory for other insurers at this time, it may come – so it is best practice to make sure this documentation is completed on all patients’ records before the order is written.

While shared decision making is fundamentally a communication activity involving clinicians and patients, decision making tools alone are not sufficient to ensure the process progresses appropriately. There are many caregivers who state that there are barriers to discussing LDCT for screening that include competing health issues of the patient, discussions taking up too much time, and the patient’s literacy levels along with a lack of decision making aids.

Patient support tools should be created in multiple formats and used to add to the decision making discussion. The Agency for Healthcare Research and Quality (AHRQ) has developed many tools that patients and their families can access to initiate conversations with their caregivers or to update themselves on the how and why this scan should be done. Among the tools are: “Is Lung Screening Right for Me? A Patient Tool,” “Is Lung Cancer Screening Right for Me? A Healthcare Professional Tool,” “Lung Cancer Screening: A Summary Guide for Primary Care Physicians,” and “Lung Cancer Screening: A Clinicians Checklist.” Once these issues are discussed, a written order for LDCT lung cancer screening must be given to the patient or electronically sent for scheduling.

But where do we as nurses fit into this scenario? Whether nurses see these patients in the navigation role, as a bedside or chairside caregiver, from the doctors’ offices to in-patient hospital care, the nursing role has always been one of bridging the gap between patient and physician. Nurses in general, and oncology nurses specifically, have always been in the position to hear what patients and families are saying – especially since many patients still feel that they “don’t want to tie up the doctors time with questions.” Nurses have allowed patients to verbalize their needs and concerns and validate what is being communicated. They can then reflect back to the patient the need to communicate with the entire healthcare team to better facilitate understanding and shared decision making. Nurses can provide information to patients and family

members. Nurses can ensure patients and family members understand the information provided. But most importantly, nurses can assist patients in the discussion of testing with their physicians.

What nurses need to know about payment of the testing is that CMS (Medicare) pays for the testing as long as the patient meets criteria and State Medicaid programs are not required to cover the cost of screening or offer only partial payment (UPI, Health News, 2019). In the State of Delaware, the Lung Screening CT is covered by Medicaid under the Department of Health’s (DPH) Screening for Life program. “All Delawareans, especially current or former smokers, should talk to their healthcare providers about getting low-dose CT scans, said DHSS Secretary Dr. Kara Odom Walker” (news.delaware.gov/2019). For more information regarding the cancer prevention and control program, visit https://www.dhss.delaware.gov/dhss/dph/dpc/cancer.htm or (https://news.delaware.gov/2019/04/17/dph-urges-delawareans-at-high-risk-of-lung-cancer) or call (302)744-1020.

For patients with personal healthcare insurance, each insurance company is a little different. As nurses, it is difficult to keep up with all programs’ information. Encourage your patient to discuss with the physicians’ office staff for pre-certifying coverage before scheduling the scan and/or have the patient call their insurance company directly to determine coverage.

ReferencesNational Lung Screening Trial Research Team. (2011) Aberle,

D.R., Adams, A.M., Berg, C.D., Black, W.C., Clapp, J. D., Fagerstrom, R.M., Gareen, I.F., Gatsonis, C., Marcus, P.M., and Sicks, J.D. Reduced lung-cancer mortality with low-dose computed tomographic screening. New England Journal of Medicine, 365(5), 395-409.

Agency for Healthcare Research and Quality. (2019). Lung Cancer Screening Tools. Retrieved from https://effectivehealthcare.ahrq.gov/decision-aids/lung-cancer-screening/home.html

Department of Health and Human Services. Centers for Medicare and Medicaid Services. (2017). Medicare Coverage of Screening For Lung Cancer With Low Dose Computed Tomography (LDCT). Retrieved from – https://www.cms.gov/medicare-coverage-database/details/NCA-decision-memo.aspx?NCAId-374

Delaware Division of Public Health Comprehensive Cancer Control and Prevention Programs. (2019). April Designated as Lung Cancer Screening Awareness Month. Retrieved from https://news.delaware.gov/2019/04/17/dph-urges-delawareans-at-high-risk-of-lung-cancer-to-get-life-Saving Screenings

Pirschel,C. (2019). How Shared Decision Making Affects Cancer Care. Oncology Nursing Society Voice. Pittsburgh: Oncology Nursing Society.

United Press International. (2019). Medicaid Coverage for Lung Cancer Varies from State to State. Retrieved from https://www.upi.com/Health News/2019/03/25/Medicaid-coverage-for-lung-cancer-varies -from-state-to-state

November, December 2019, January 2020 DNA Reporter • Page 5

Trina M. Turner, MSN, RN-BC, LNC

Trina M. Turner earned her BSN and MSN (with a concentration in Legal Nurse Consulting) from Wilmington University in New Castle, Delaware. She is a board-certified Progressive Care Nurse and has worked in critical care, interventional radiology, and ambulatory surgery as both a direct care nurse and nursing supervisor for 25 years. She is currently a lung and colorectal nurse navigator at Bayhealth Medical Center, Kent and Sussex Campuses, working with patients to educate, provide community outreach, and assist with lung and colorectal screenings. Part of her position is in collaboration with the Delaware Department of Health and Social Services, providing patients with resources such as Screening for Life, a program that offers uninsured or underinsured patients free or low cost health screenings. Additionally, she has recently become a Delaware Tobacco Cessation Face-to-Face Coach with the Delaware Quit Line. Trina is a member of Bayhealth’s Community Outreach Task Force Committee, the Sussex County Health Coalition, and the IMPACT Delaware Tobacco Prevention Coalition. Trina can be reached by email at Trina_Turner@Bayhealth.org or at her office at (302) 744-6831.

Trina M. Turner

The Role of Smoking Cessation in Lung Screening Navigation

Tobacco use plays a significant role in the number of newly diagnosed lung cancer cases. Smoking and tobacco use have been deemed the leading cause of lung cancer (American Lung Association [ALA], 2018). In the state of Delaware, the smoking rate is currently 17.4 percent, which is slightly higher than the national average of 16.8 percent. Having the ability to quit using tobacco products is vital to the overall health of the community. Tobacco use affects every major body system (i.e. cardiovascular, pulmonary, and renal); however, tobacco cessation is imperative to reduce the risk of developing cancer.

Research has shown that while smoking and tobacco use quit rates and quit attempt rates are relatively high shortly after a cancer diagnosis, the relapse rates are also high (Karam-Hage, Cinciripini, & Gritz, 2014). Among cancer patients and survivors, it is essential for healthcare providers to screen, treat, and prevent the patients from returning to tobacco use. Additionally, research has proven that when used in combination, pharmacologic and behavioral interventions achieve the highest smoking cessation rates, with a recent emphasis on individualized treatment as the most promising approach (Karam-Hage, et al., 2014).

Among health care systems, challenges exist that have slowed significantly the process in getting patients screened for tobacco cessation. Some of the issues include, but are not limited to; the lack of appropriate resources and provider training needed to develop, sustain, and achieve a deliverable program that meets the needs of the community. It is recommended that when oncology providers are screening their patients for tobacco use, the patient should be referred to specialized treatment programs, such as quit lines where available (Karam-Hage, et al., 2014). Quit lines provide patients with trained professionals that provide support and education specifically for tobacco cessation.

A limited amount of data exists about the effectiveness of implementing a tobacco cessation program into lung cancer screening. According to Fucito et al, (The Association for the Treatment of Tobacco Use and Dependence/Society for Research on Nicotine and Tobacco Synergy Committee) (2016), the absence of adequate data should not preclude the implementation of evidence-based smoking-cessation support for lung cancer screening patients. Integrating smoking-cessation treatments with lung cancer screening may increase quit smoking rates and the overall cost-effectiveness of screening, although more research is needed to confirm this

theory (Fucito et al., 2016). Although successful smoking-cessation interventions (medications and counseling) are well established, the structure of cessation support (i.e., access to tobacco treatment) needs to be developed further. The authors recommend that a dedicated service in a Low Dose Cat Scan (LDCT) facility or a dedicated clinician with tobacco treatment experience be integrated into the lung cancer screening treatment team to provide tobacco cessation services (Fucito et al., 2016).

The Delaware Quit Line and Lutheran Community Services offer a free two-day training course to enable nurses and other clinicians to become a Delaware Quit Line Face-to-Face Tobacco Cessation Coach. Cessation coaching is an exciting addition that can be incorporated in the role of lung-screening navigation. Navigators will have the ability to not only educate and assist patients with obtaining screenings; they can also navigate patients to tobacco cessation services, which is a much-needed resource in the community. Moreover, the face-to-face tobacco cessation coaching will offer patients a personal connection that not only helps to improve the quality of their lives, but will also offer them an alternative option to the telephone and online support (HealthyDelaware.org, 2019).

Smokers who get help from their health care provider or a trained counselor triple their chances of quitting for good. Evidence-based research shows that cancer patients who quit smoking having an improved response to their chemotherapy and radiation treatment, and non-cancer patients have improved healing after surgery, improved cardiac and respiratory health, and better control over chronic illnesses. Through the Delaware Quit Line, patients may qualify to receive free nicotine-replacement therapy and pharmaceuticals. All tobacco cessation coaches must have a current license or certification in their respective health care field, have at least a Bachelor’s degree or higher, be a NON-SMOKER, have a phone number that can be

used to receive client referrals, and an email account that is checked frequently.

One caveat to the program is that DHSS (Delaware Department of Health and Social Services) employees may take the training to support tobacco cessation coaching activities in their current positions, but they are not eligible to serve as an independent contractor under this program. For more information on the Delaware Quit Line Face to Face Tobacco Cessation Coaching, please contact the tobacco program manager, Jo Wardell, by email at jo.wardell@optum.com or by phone at (302) 383-7836.

In the fight against lung cancer, screening and prevention is imperative. Along with LDCT lung screening, integrating a tobacco cessation program is a vital resource for the community. These services not only help to improve patient health outcomes, but also helps to improve their quality of life.

ReferencesDelaware Lung Cancer Rates. (2018, February 27).

Retrieved from: https://www.lung.org/our-initiatives/research/monitoring-trends-in-lung-disease/state-of-lung-cancer/states/DE.html

Fucito, L. M., Czabafy, S., Hendricks, P. S., Kotsen, C., Richardson, D., Toll, B. A., & Association for the Treatment of Tobacco Use and Dependence/Society for Research on Nicotine and Tobacco Synergy Committee. (2016). Pairing smoking-cessation services with lung cancer screening: A clinical guideline from the Association for the Treatment of Tobacco Use and Dependence and the Society for Research on Nicotine and Tobacco. Cancer, 122(8), 1150–1159. doi:10.1002/cncr.29926

Healthy Delaware. (2019, March 28). Tobacco cessation and your patients. Retrieved from: https://www.healthydelaware.org/Healthcare-Providers/Tobacco-Cessation

Karam-Hage, M., Cinciripini, P. M., & Gritz, E. R. (2014). Tobacco use and cessation for cancer survivors: Ann overview for clinicians. CA: A Cancer Journal for Clinicians, 64(4), 272–290. doi:10.3322/caac.21231

Bayhealth RN’s are Driven. We are Hiring!Bayhealth is the largest healthcare provider in central and southern Delaware. We are comprised of two acute care centers Kent and Sussex Campus, the freestanding Emergency Department in Smyrna as well as numerous satellite facilities and employed physician practices encompassing a variety of specialties. We are a Magnet and Planetree Silver-Level Designated hospital system.

As a reputable community based health system, we are focused on the diverse needs of our patients delivering evidence based award winning care. Our exceptional outcomes are driven by Bayhealth’s core values of compassion, accountability, respect, integrity and teamwork.

Bayhealth’s nursing culture is rooted in teamwork and is empowered through a passionate shared governance model.

We are seeking RN’s who are DRIVEN to serve patients in a way that creates a healthier community and supports our Planetree philosophy of patient and family centered care.

Apply Today - Positions available:

• Acute care levels and specialty areas• Leadership Opportunities• Graduates Welcome!

https://www.bayhealth.org/careersEOE M/F/D/V

Page 6 • DNA Reporter November, December 2019, January 2020

Lisa Moore, MPA and Nora C. Katurakes, MSN, RN, OCN®

Lisa Moore received her BA in Psychology and Masters of Public Administration from the University of Delaware. Lisa has worked within the Delaware Division of Public Health for twenty years and currently manages the Tobacco Prevention and Control Program. She is a certified Quality Improvement Associate through the American Society of Quality. Lisa also facilitates an online course for the University of Phoenix, Health Care Quality Management and Outcome Analysis. Lisa can be reached at lisa.m.moore@delaware.gov or 302-744-1010.

See the bio & photo for Nora C. Katurakes, MSN, RN, OCN® on page 1.

Lisa Moore

How Health Care Providers Can Address E-Cigarette Use

There is a lot of conflicting information circulating about e-cigarette use. E-cigarettes are electronic devices that produce an aerosol by heating a liquid. E-cigarettes go by various names including “e-cigs,” “vapes” and “JUULs.” Proponents of e-cigarettes say that they help people quit smoking regular combustible cigarettes and are the safer alternative. Currently, there is not enough research available to support these claims. According to the Centers for Disease Control and Prevention (CDC) (2018 scientists are still learning about the long-term health effects of e-cigarettes. E-cigarettes are not a U.S. Food & Drug Administration (FDA) approved smoking cessation aid.

E-cigarettes have a battery-operated component that heats a liquid that contains nicotine, f lavorings, and other chemicals. Heating the liquid (e-juices) causes formation of an aerosol which users inhale into their lungs. These electronic smoking devices come in different shapes and sizes and can look like regular cigarettes, pens, and even f lash drives (similar to the popular brand “JUUL”).

The FDA does not regulate the content of the “e-juices,” so not everyone is aware that there is nicotine in most e-cigarettes in varying amounts. Some pods of e-cigarettes contain as much nicotine as one pack of cigarettes (Truth Initiative, 2019). The sleek shapes and appealing f lavors such as cotton candy, mango, cucumber, and strawberry have made e-cigarettes especially enticing to youth.

Youth use of e-cigarettes has surpassed youth use of regular combustible cigarettes in Delaware. According to the 2017 Delaware Youth Risk Behavior Survey (YRBS) of public high school students conducted by University of Delaware on behalf of Delaware Health and Social Services, 13.6 percent of students had used e-cigarettes in the past month while 6.2 percent smoked regular cigarettes. Approximately 38 percent of Delaware high school students reported ever trying an electronic vapor product (University of Delaware, n.d.).

Although e-cigarettes don’t contain all of the chemicals as cigarettes, there are still health risks from using them especially for youth. According to CDC (2018), e-cigarettes risks include the following:

• Nicotine is highly addictive, and can harm adolescent brain development, which continues into the early to mid-20s.

• E-cigarettes can contain other harmful substances besides nicotine.

• Many young people who use e-cigarettes also smoke cigarettes. There is some evidence that young people who use e-cigarettes may be more likely to smoke cigarettes in the future.

• Some of the ingredients in e-cigarette aerosol could also be harmful to the lungs in the long-term. For example, some e-cigarette f lavorings may be safe to eat but not to inhale because the gut can process more substances than the lungs.

• Defective e-cigarette batteries have caused fires and explosions, some of which have resulted in serious injuries.

Experimentation with e-cigarettes is also catching on with adults. According to the 2017 Behavior Risk Factor Survey (BRFS) conducted by Delaware Health and Social Services, 4.8 percent of Delaware adults currently use e-cigarettes, roughly the same reported in the 2016 survey. However, within the adult demographic, 12.7 percent of 18-24-year-old adults and 21.3 percent of males, ages 18-24 are "current users" of e-cigarettes (Delaware Health and Social Services, n.d.).

Health care providers can screen for tobacco use and advise patients to quit if they do use tobacco products. Providers can refer tobacco users 18 years and older to the Delaware Quitline (1-866-409-1858) for free help in quitting tobacco products. For providers that participate in the Quitline fax referral program, with patient consent, the Quitline will call patients directly. For patients under 18 years, providers should educate them on the dangers of tobacco use, especially e-cigarettes. According to the United

States Department of Health and Human Services (2019), teenagers are more likely to get information on health issues from their parents and their health care providers than from peers, the internet, or social media. Tobacco users under 18 years can be referred to the American Lung Association in Delaware to connect them with a student wellness center that has staff trained in Not on Tobacco (NOT). There is also a national text campaign run by the TRUTH Initiative to help teens quit e-cigarettes called “This Is Quitting.”

Delaware has taken a comprehensive approach in combating e-cigarette use as well as tobacco use in general. Tobacco use is still the leading preventable cause of death in Delaware and the United States. Since 95% of adult smokers begin smoking before they turn 21, one of the steps that Delaware took was to raise the age to purchase tobacco products from 18 years to 21 years. This law took effect in July 2019. Other policies that have shown to reduce tobacco use initiation and prevalence are increases to tobacco excise taxes. The Division of Public Health conducted focus groups with youths and used their input to develop multi-media campaigns on e-cigarettes. Delaware Kick Butts Generation and Delawareans Against Nicotine and Tobacco Exposure (a youth led and young adult led groups) educate their peers on the hazards of e-cigarettes and other tobacco products.

There are several resources that can be used to learn more about e-cigarettes:

Delaware Tobacco Prevention and Control Program https://www.dhss.delaware.gov/dhss/dph/dpc/tobacco.htmlThe Dirty Truthhttp://www.thedirtytruth.com/Healthy Delawarehttps://www.healthydelaware.org/Healthcare-Providers/Tobacco-CessationSurgeon General Health Care Professional E-cigarette Guidehttps://e-cigarettes.surgeongeneral.gov/documents/SGR_E-Cig_Health_Care_Provider_Card_508.pdfCenters for Disease Control and Prevention https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html Campaign for Tobacco Free Kidshttps://www.tobaccofreekids.org/assets/factsheets/0379.pdf

Delaware has made great strides in preventing initiation of combustible cigarettes, as youth smoking rates are at an all time low (University of Delaware, n.d.). However, youth are becoming increasingly addicted to e-cigarettes and as new information emerges on the dangers of these products, we must be diligent in providing education and raising awareness about the risks. Health care professionals can play a large role in helping to curtail e-cigarette use by providing credible information to their patients.

ReferencesCenters for Disease Control and Prevention. (2018).

About Electronic Cigarettes. Retrieved from https://w w w.c d c . g o v/t o b a c c o/ b a s i c _ i n f o r m a t i o n/e -cigarettes/about-e-cigarettes.html

Delaware Health and Social Services. (n.d.). More than One of Five Delaware Adults Now Use Tobacco Products. Retrieved from https://www.dhss.delaware.gov/dhss/dph/dpc/tobacco2017brfs.html

Truth Initiative. (2019). How Much Nicotine is in JUUL?. Retrieved from https://truthinitiative.org/research-resources/emerging-tobacco-products/how-much-nicotine-juul

United States Department of Health and Human Services. (2019). Health Care Professionals: Education Your Patients About The Risks Of E-Cigarettes. Retrieved from https://e- cigarettes.surgeongeneral.gov/documents/SGR_E-Cig_Health_Care_Provider_Card_508.pdf

University of Delaware. (n.d.). Center for Drug and Health Studies, Youth Risk Behavior Survey. Retrieved from https://www.cdhs.udel.edu/content- subs i t e/Docu ment s/2017 %20Ep i%20Report/2017%20DE%20HS%20Trend%20Report.pdf

November, December 2019, January 2020 DNA Reporter • Page 7

Ginny Pugh, BSN, RN, OCN

Ginny Pugh earned her Bachelor of Science degree in Psychobiology from Albright College, Nursing Diploma from Reading Hospital School of Health Sciences, and BSN from Chamberlain College of Nursing. She is currently enrolled in Wilmington University for her MSN. Ginny is certified in oncology nursing. Ginny has worked in various oncology positions. She has worked as an inpatient oncology nurse on an oncology medical/surgical unit and as a staff nurse in an outpatient radiation oncology department. She is currently employed as an oncology nurse navigator at Helen F. Graham Cancer Center and Research Institute at Christiana Care Health Systems where she coordinates care for the head/neck & GU patient population from the time of diagnosis throughout the cancer continuum. Ginny also serves as the Chair of the Helen F. Graham Oncology Practice Council where she leads interdisciplinary initiatives for the cancer center and various oncology clinicians. Ginny can be reached by email at vpugh@christianacare.org or by phone at (302) 623-4753.

Ginny Pugh

From the early 1900s, navigation has proven to play an important role in decreasing time to care when a patient is diagnosed with a medical condition (Strusowski, Sein, & Johnston, 2017). When a patient receives the diagnosis of lung cancer their lives can quickly turn to chaos, and fear of the unknown can be overpowering and frightening. During the time of diagnosis, a patient may be unsure where to turn or what first step needs to be taken to get connected to appropriate providers. In a healthcare system that can be fragmented at times, lung cancer patients often have multiple providers and disciplines involved in their care. The healthcare system is an incredibly complex system that includes a diverse range of allied health professionals with multiple disciplines in a variety of fields (Collett et al., 2019). In addition, there are multiple modalities of treatment for these patients to include surgery, chemotherapy, radiation, or a combination of all the above. Often the focus from the medical team involved in the patient’s care becomes focused on the patient’s treatment and hope for a cure of the cancer. This is where the help and assistance of an oncology nurse navigator (ONN) becomes invaluable to the cancer patient. The ONN serves as a bridge between medical treatment and supportive services for the patient. The role of the ONN is to help provide lung cancer patients with comprehensive and individualized care. Oncology nurse navigators can assist lung cancer patients with identifying barriers in their care, facilitating discussions among their healthcare providers, coordinating physician appointments, providing additional education on their cancer and treatment plan, and connecting these patients with the appropriate resources and services they may need throughout the cancer care continuum.

Symptoms and side effects of cancer and cancer treatment is a burden that lung cancer patients will inevitably have to endure. With the help of the ONN, these symptoms can be tackled quicker as the ONN is in constant communication with the patient and the oncologists, as they follow them through treatment. Despite being an overwhelming time for the patient and their family, studies on navigation programs have shown that connecting a cancer patient with an oncology nurse navigator from the beginning, improves the timeliness of their care (Wagner et al., 2013). By building a trusting relationship with the lung cancer patient, the ONN becomes an advocate for them to assist with psychosocial support and help with treatment decision making.

Oncology nurse navigators meet with lung cancer patients initially at diagnosis, or soon thereafter, in a multidisciplinary clinic setting or in the individual oncology offices. Immediately, the ONN begins detailing the timeline of events for the patient and starts to coordinate and expedite physician appointments. They also work on connecting lung cancer patients

to resources and supportive services that will be needed before, during, and after treatment. These supportive services can include social workers, registered dietitians, health psychologists, pain and palliative care support specialists, physical and occupational therapists, and a variety of other services. Oncology nurse navigators continually follow up with the patient before and during cancer treatment to ensure the patient has no delay in care. They are often called the “quarterback” of the cancer team, as they help drive the lung cancer patient through the healthcare system, ensuring that the patient and their families are where they need to be, when they need to be there. Oncology nurse navigators will frequently check in with patients or their family members during treatment to verify and monitor that treatment stays on track. If there is an unexpected interruption or delay in the lung cancer patient’s treatment or appointments with providers, the ONN will make sure that the patient gets re-connected as soon as possible so that the patient does not “fall through the cracks.”

In summary, the ONN offers individualized patient care for each lung cancer patient with the goal of supporting the individual and their family through the cancer care continuum. This coordination between the ONN and the lung cancer patient allows optimization of cancer care delivery, which will improve the patient’s experience and outcome of their treatment (Collett et al., 2019). The partnership and support that the ONN provides to the lung cancer patient helps improve their experience with cancer care and reduces the burden of symptoms. This results in an increase in patient satisfaction with the care they have received and improvement in their overall health status (Lee et al., 2011). For lung cancer patients and their families, the ONN is an instrumental part of their cancer care team to help provide and support best outcomes of lung cancer treatment physically, mentally, and emotionally.

References:Collett, G., Durcinoska, I., Rankin, N., Blinman, P., Barnes, D., Anderiesz, C.,

& Young, J. (2019). Patients’ experience of lung cancer care coordination: A quantitative exploration. Supportive Care in Cancer, 27, 485-493.

Lee, T., Ko, I., Lee, I., Kim, E., Shin, M., Roh, S., Yoon, D., Choi, S., & Chang, H. (2011). Effects of nurse navigators on health outcomes of cancer patients. Cancer Nursing, 34(5), 376-380.

Strusowski, T., Sein, E., & Johnston, D. (2017). Academy of oncology nurse and patient navigators announces standardized navigation metrics. Journal of Oncology Navigation and Survivorship, 8(2), 62-68.

Wagner, E., Ludman, E., Bowles, E., Penfold, R., Reid, R., Rutter, C., Chubak, J., & McCorkle, R. (2013). Nurse navigators in early cancer care: A randomized controlled trial. Journal of Clinical Oncology, 32(1), 12-18.

Nurse Navigation: Improving a Patient’s Experience and Outcome

Making an impact in the lives of Others...

Every Day we work as One.• Work in a new TCU

• State of the art equipment & technology

• Faith Based Organization

Apply On-Line / Call 302-744-3510

1175 McKee Road, Dover, DE 19904

wmvdover.orgE.O.E.

Page 8 • DNA Reporter November, December 2019, January 2020

Since the earliest days of chemotherapy clinical trials in the 1960s, oncology nurses have been involved with clinical research. The oncology nurse role has evolved over the years and includes different variations of title, all of which may include clinical nursing practice, study management, coordination and continuity of care, human subjects protection (i.e., conducting the informed consent process), and contributing to the science of clinical research by being part of the research team and adhering to the current protocol(s) and/or by coming up with new ideas and innovations for research (Schmotzer & Ness, 2016). Research Nurse Coordinators at the Christiana Care Health System (CCHS) are responsible for verifying patient eligibility at study entry and the overall management of the patient while they remain on a clinical trial. Research Nurse Coordinators assess for compliance, efficiency, safety, and welfare of participants while they are on a trial. Research Nurse Coordinators are another set of eyes for the patient as they are going through this journey.

CCHS has been conducting cancer research for over fifty years. The oncology program has been federally funded from the National Cancer Institute (NCI) since 1987. The designations have evolved over the years from a Community Clinical Oncology Program (CCOP) to a National Cancer Institute (NCI) Community Oncology Research Program (NCORP). The NCORP distinction is only awarded to 46 sites in the United States. In May 2002, the Helen F. Graham Cancer Center and Research Institute (HFGCC&RI) opened as a center providing coordinated care to patients in the tri-state area. In 2001, HFGCC &RI began developing a relationship with the pharmaceutical industry, which has provided further access to clinical trials for patients not available through the NCI (Kandie Dempsey, interview by Tammy Layer, July 15, 2019).

CCHS has participated in many pivotal lung cancer trials, which include treatment, prevention, and cancer control trials. Clinical trial results can vary with each study; some may have results that change how patients are treated and/or how care is delivered, while others show which treatment regimens are the best option for patients.

An important cancer control study, which CCHS took part in, was the Early Lung Cancer Action Project (ELCAP) study, which evaluated baseline and annual repeat screening by low-radiation-dose computed tomography (LDCT) in people at high risk of lung cancer. ELCAP enrolled 1000 asymptomatic participants, aged 60 years or older, with at least 10 pack-years of cigarette smoking and no previous cancer, who were medically fit to undergo thoracic surgery. Compared with chest radiography, low-dose CT greatly increases the likelihood of detection of small non-calcified nodules and, thus, of lung cancer at an earlier and more curable stage. On LDCT, non-calcified nodules were detected three times as commonly as on chest radiography, malignant tumors four times as commonly, and stage I tumors six times as commonly. Additionally, the malignant tumors detected on LDCT were substantially smaller than those detected on chest radiography, even within stage I; 15 (56%) tumors detected on LDCT measured 10 mm or less compared with only two tumors detected on chest radiography. (Henschke et al., 1999)

A pivotal treatment trial that CCHS participated in was RTOG 0617 [A Randomized

Phase III Comparison of Standard Dose (60 Gy) Versus High dose (74 Gy) Conformal Radiotherapy with Concurrent and Consolidation Carboplatin/Paclitaxel +/- Cetuximab in Patients with Stage IIIa/IIIb Non-Small Cell Lung Cancer]. A total of 544 were randomized, including 166 to standard-dose chemoradiotherapy, 121 to high-dose chemoradiotherapy, 147 to standard-dose chemoradiotherapy and cetuximab, and 110 to high-dose chemoradiotherapy and cetuximab. This trial revealed that standard dose chemoradiotherapy is preferable to high dose chemoradiotherapy and that cetuximab (Erbitux) offers no additional survival benefit for these patients (Bradley et al., 2016).

An important trial that CCHS contributed to which revealed a change in how patients are currently treated was a pharmaceutical trial supported by Merck, KEYNOTE-189 [Phase 3 study of platinum-based chemotherapy with or without pembrolizumab for first-line metastatic, nonsquamous non-small cell lung carcinoma (NSCLC)]. In this trial, 616 patients with metastatic nonsquamous NSCLC without sensitizing ALK or EGFR mutations who had not received treatment for metastatic disease were randomized to receive pemetrexed and a platinum-based agent plus pembrolizumab or placebo every three weeks for four cycles followed by pembrolizumab or placebo for up to 35 cycles plus maintenance pemetrexed. This game-changing trial showed that adding immunotherapy with chemotherapy provided “significantly” higher response rates (47.6% in the pembrolizumab-combination group versus 18.9% in the placebo-combination group) and longer progression-free survival (median of 8.8 months in the pembrolizumab-combination group versus a median of 4.9 months in the placebo-combination group) with the addition of pembrolizumab to standard chemotherapy (Ghandi et al., 2018). Immunotherapy therapies such as pembrolizumab, are a much more tolerable medication for patients compared with chemotherapy. Patients do not get the toxicities that chemotherapy delivers; this allows for an improved quality of life while receiving treatment for their lung cancer.

Research nurse coordinators facilitate the day to day requirements of each trial, guiding physicians, staff, and patients to the requirements of each trial. Each trial varies with the complexity of requirements and may include anything from periodic quality of life surveys to standard of care physical examinations, laboratory work, and scans to intensive pharmacokinetic and pharmacodynamic blood sampling and additional repeated tumor biopsies. The research nurse is responsible to ensure compliance and data integrity are maintained and that all data collection points are met, while also ensuring patient safety. Without clinical trials, we would not be able to advance our treatment of oncology patients in their fight against cancer.

ReferencesBradley, J., Paulus, R., Komaki, R., Masters, G.,

Blumenschein, G., Schild, S., ... Choy, H. (2015). Standard-dose versus high-dose conformal radiotherapy with concurrent and consolidation carboplatin plus paclitaxel with or without cetuximab for patients with stage IIIA or IIIB non-carboplatin plus paclitaxel with or without cetuximab for patients with stage IIIA or IIIB non-small-cell lung cancer (RTOG 0617): A randomized, two-by-two factorial phase 3 study. THE LANCET: Oncology, 16(2).

Gandhi, L., Rogriguez, D., Gadgeel, S., Esteban, E., Felip, E., DeAngelis, F., Bischoff, H. (2018). Pembrolizumab plus Chemotherapy in Metastatic Non-Small Cell Lung Cancer.

New England Journal of Medicine, 378(22), 2078-2092.

Henschke, C., McCauley, D., Yankelevitz, D., Naidich, D., McGuinness, G., Miettinen, O., et al. (1999). Early Lung Cancer Action Project: overall design and findings from baseline screening. THE LANCET, 354, 100-105.

Schmotzer, G., & Ness, E. (2016). The Research Team. In A. Klimaszewski, M. Bacon, J.Eggert, J. Westendorp, & K. Willenberg (Eds.), Manual for Clinical Trials Nursing (3rd ed., pp. 81-87). Pittsburgh, PA: ONS Publications.

Elizabeth Conway, BSN, RN andTammy Layer, MSN, RN, OCN

Elizabeth Conway earned her BBA in Finance from St. Joseph’s University and later her BSN from the Villanova University. Liz works as a Research Nurse Coordinator and Cancer Care Delivery Research lead at the Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System. She previously worked as a staff nurse at Thomas Jefferson University Hospital and Fox Chase Cancer Center. Liz worked in oncology research at Fox Chase Cancer Center and UPenn’s Abramson Cancer Center, and has worked for 5+ years in regulatory medical writing and quality review and quality control. She is currently a Research Nurse Coordinator at the Helen F. Graham Cancer Center & Research Institute and works primarily on Cancer Care Delivery Research, Cancer Control, and Prevention studies and serves on the department QA committee. Liz volunteers as a teacher’s aide for Catholic Youth Faith Formation at her local parish. Liz can be reached by email at elizabeth.m.conway@christianacare.org or her office at (302) 623-4789.

Tammy Layer earned her BSN and MSN from Wilmington University. She is a Certified Oncology Nurse. Tammy has worked in various Oncology positions during her 30 years of nursing. Currently she is working in Cancer Research at Christiana Care Health Services at the Helen F. Graham Cancer Center and Research Institute. Tammy is also an adjunct instructor at Wilmington University. She is a member of the Delaware Chapter of Oncology nurses and is a member of the Board. Tammy is Chair-elect for the Nursing Practice Council at HFGCC. She volunteers for Delaware Special Olympics. Tammy can be reached via email at tlayer@christianacare.org or her office at (302) 623-4579.

Elizabeth Conway

Tammy Layer

Lung Cancer and Nursing Research Coordinators – What’s The Connection?

NursingALD.comcan point you right to that perfect

NURSING JOB!

NursingALD.com

E-mailed Job Leads

Easy to Use

Privacy Assured

Free to NursesGary W. aldersonattorney at laW, reGistered nurse

November, December 2019, January 2020 DNA Reporter • Page 9

Oncology nurses have been waiting for many years for new therapies for lung cancer. Immunotherapy, also referred to as Immune Checkpoint inhibitor therapy, is an exciting treatment option for the control of lung cancer. It has arrived and is here to stay! Nurses will need to go back to the books and learn about the immune system and the unique side effects associated with this treatment. Kottschade (2018) noted that the

side effects of treatment are unlike anything that has been experienced in oncology so far as immune-related adverse effects are a result of direct manipulation of the immune system.

According to Dong and Markovic (2018), cancer immunotherapy uses the immune system to control cancer. Rather than targeting cancer cells, immunotherapy is aimed at enhancing the capability of the immune cells to recognize and destroy cancer cells. PD–L1 (Programmed Death Ligand-1) blockade is required to improve this antitumor immunity. PD-L1 is used by cancer cells to disarm the immune system (Kottschade, 2018).

In 2017, the FDA approved Nivolumab (Opdivo) for individuals with metastatic non-small cell lung cancer who had disease progression after receiving chemotherapy (Keil, 2019). Since that time, other immunotherapy drugs have been approved for patients with metastatic non-small cell lung cancer (Cope, Reb, Schwartz, & Simon, 2018).

Another option for treatment with an immune checkpoint inhibitor came about when a practice changing study showed that Durvalumab (Imfinzi), when used for unresectable Stage III non-small cell lung cancer after radiation and concurrent chemotherapy, showed significant progression-free survival of 16.8 months vs. 5.6 months with placebo (Kiel, 2019). Overall survival is the true measurement of how effective a treatment is.

When chemotherapy is discontinued, or the doses are adjusted, the side effects generally resolve on their own. The immune-related adverse events of immunotherapy treatment may involve one or more of the body’s systems. The toxicity is directly related to over-activation of the immune system and can have a delayed onset and last for months after withdrawal of the agent (Kottschade, 2018). Why is this important for nurses to understand? Immune–related adverse events need to be recognized early and treated quickly to prevent morbidity. The lung cancer patient receiving immunotherapy may seek treatment in a dermatology office, an endocrine office, a medical office, or even an emergency room. Sometimes, even with previous teaching, they do not have the understanding that they must call their oncologist when the immune related adverse event occurs.

According to Wood (2019), there are twelve toxicities that can be seen. Most common are skin rash with or without pruritus, diarrhea/colitis, thyroiditis,

and hepatic dysfunction. Less common involving the endocrine system include hypophysitis, adrenal insufficiency, diabetes, and pneumonitis. Toxicities that are easily overlooked include arthralgia/arthritis, mucositis/xerostomia, neuropathy, and nephritis.

Patient teaching about immunotherapy prior to initiating treatment is extremely important. Immune-related adverse events may become so severe that the patient may be brought to the emergency room first. For instance, in the case of severe diarrhea with abdominal pain, the CT scan will show colitis. The provider will rule out infection. The problem occurs when the patient is aware of being treated for lung cancer, but cannot recall what it is due to being drowsy from the analgesia for the abdominal pain. How does the treatment for immune therapy-induced colitis differ from the standard of care? Because of this, patient education resources available through the Oncology Nursing Society include free wallet cards specifically for individuals who are receiving immunotherapy to alert non-oncology clinicians of the most common side effects and management strategies of these new medications. There is a need for prompt imitation of treatment with steroids to prevent life-threatening complication of perforation (Wood, 2019).

Lung cancer treatment has come a long way from the days of standard chemotherapy and radiation. Immunotherapy is truly amazing, but the adverse events associated with it are unique. All nurses should become familiar with immune checkpoint inhibitor therapy and the adverse events that may occur.

ReferencesCope, D., Reb, A., Schwartz, R. Simon, J. (2018). Older adults

with lung cancer. Clinical Journal of Oncology Nursing, 22 (6), 26-33.

Dong, H. & Markovic, S. (Eds.) The Basics of Cancer Immunotherapy. Switzerland: Springer.

Kiel, P. (2019). 2017-2018 Drug approvals in solid tumors. Journal of the Advanced Practitioner in Oncology, 10 (3), 218-224.

Kottschade, L. (2018). Management of Immune-Related Adverse Events from Immune Checkpoint Inhibitor Therapy in Dong, H. & Markovic, S. (Eds.) The Basics of Cancer Immunotherapy. (pp.143-150). Switzerland: Springer.

Wood, L. (2019). Immune-Related Adverse Events from Immunotherapy: Incorporating care step pathways to improve management across tumor types. Journal of the Advanced Practitioner in Oncology, 10, 47-62.

The role of Supportive and Palliative Care (SPC) is to provide an extra layer of support for patients with a chronic or serious illness. For patients with lung cancer, palliative care is appropriate at all stages of the illness; from initial diagnosis until end of life. The SPC team are specialists who are trained in having difficult conversations with patients and loved ones to discuss their illness and prognosis. They assist patients and families in understanding their treatment options and goals of care by facilitating family meetings to ensure all members of the patient’s primary team are collaborating, educating, and listening to patients and families concerns are in alignment with patient’s goals.

The World Health Organization (WHO) defines palliative as:

An approach which improves the quality of life when patients and families are facing life-threatening illness, through the prevention and relief of suffering early through identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual. (WHO, 2017)Treatment for lung cancer may include surgery,

radiation, chemotherapy and/or immunotherapy. Each of these treatment options have side effects which the SPC team can help by providing recommendations for medications and referrals to other supportive services such as rehabilitation and nutrition. Common symptoms that can be improved through the support of SPC include pain, shortness of breath, fatigue, nausea, constipation, loss of appetite, problems with sleep, anxiety, and depression. After lung cancer

treatment it is likely that the patient will continue to experience several symptoms as they recover requiring continued support from the SPC team.

Increased symptom burden from advanced lung cancer treatment is associated with poor quality of life (Iyer, Roughley, Rider and Taylor-Stokes, 2014). Symptom burdens are subjective cancer symptoms that produce negative physical and emotional responses for the patient. Iyer et al (2014) performed a study to evaluate symptom burden in advanced non-small cell lung cancer (NSCLC), and how it impacts a patient’s quality of life (QOL) as well as the perception of severity of symptoms between physician and patient. In this study, it was noted that a significant number of patients experienced lung cancer symptoms including fatigue, loss of appetite, and shortness of breath, cough, pain, and blood in sputum and that symptom burden had a negative effect on the QOL in patients with advanced stage NSCLC.

Obtaining support for an early referral to the SPC team from the primary team and specialists for symptom management is key. Referral rates are much higher when there is the convenience of a palliative provider or team. Further research is needed on the importance of referral to SPC for psychological and emotional support to include complex emotional states of grief, sadness, fear of pain, death, anxiety, and loss versus solely for disease and symptom management (Johnson, Girgis, Paul, & Currow, 2011).

Immunotherapy and Lung Cancer

Constance Hill, MSN, RN, APRN-CFNP AOCNP®

Constance Hill earned her BSN and MSN from Wilmington College in New Castle, DE. She is an Advanced Oncology Certified Nurse Practitioner and is certified as a Family Nurse Practitioner. Constance worked as an oncology Nurse Practitioner in a private Hematology/Oncology practice at the Helen F. Graham Cancer Center & Research Institute for nine years. She then joined a different Hematology/Oncology private practice at the same location. The practice joined Christiana Care Health System in 2018. Previously she worked in oncology as an LPN and then an RN starting in 1975. Constance has worked in various RN positions in Northern California as a travel nurse for five years. She also worked as a consultant speaking nationally for Genentech, Novartis and Celgene and as a Panel Advisor for Seattle Genetics. Constance is currently an oncology hematology hospitalist nurse practitioner at Christiana Care. She is a member of the ASCO, DSCO, and the Delaware Diamond Chapter of the Oncology Nursing Society. She served as chapter president and newsletter writer for many years. Constance can be reached by email at Constance.Hill@christianacare.org or her office at (302) 731-7782.

Constance Hill

LaTonya E. Mann, DNP, FNP-BC, OCN®

Dr. Mann earned her Licensed Practical Nurse degree from Salem Community College, Associate Degree in Nursing from Gloucester County College, Bachelors in Nursing from Immaculata University, Master’s Degree from University of Delaware, and Doctorate in Nursing from Wilmington University. She is board certified as a Family Nurse Practitioner. LaTonya serves as Past President for Delaware Diamond Chapter of Oncology Nursing Society and is also a member of the Delaware Nurses Association, Delaware Coalition of Nurse Practitioners, and Sigma Theta Tau International Honor Society of Nursing. LaTonya brings over 30 years of experience in various settings of nursing including medical surgical, intensive care, home infusion therapy, and oncology nursing. She presently works as a Nurse Practitioner with the Supportive and Palliative Care Team at Christiana Care Health System. LaTonya can be reached by email at lamann@christianacare.org or at 302-733-4186.

Supportive and Palliative Care in Lung Cancer

LaTonya E. Mann

Supportive and Palliative Care in Lung Cancercontinued on page 10

Page 10 • DNA Reporter November, December 2019, January 2020

Membership Activation Form

LPN Member Benefits LPN members enjoy discounts to DNA educational activities and events, receive the quarterly DNA Reporter, nursing updates via the DNA E-News, and networking opportunities.

Web Join online. Visit us at www.denurses.org

Mail Delaware Nurses Association 4765 Ogletown-Stanton Rd, Suite L10, Newark, Delaware 19713

Essential Information

First Name/MI/Last Name Credentials

Mailing Address Line 1 Highest level degree earned

Mailing Address Line 2 Phone Number Home Work

City/State/Zip Email Address

Professional Information

Employer Current Position Title: (ie: staff nurse)

Type of Work Setting: (ie: LTC, Ambulatory Center)

What is your primary role in nursing?

Administrator/supervisor staff

Discharge planner/case manager

Educator

Office nurse

Researcher/consultant

Quality assurance/infectious control

Staff nurse

Not currently working in nursing

Other nursing position

Practice Area: (ie: pediatrics)

Current Employment Status: (ie: full-time nurse)

The annual membership fee is $154/annually.

LPNs TO THE DELAWARE NURSES ASSOCIATION!

WE

LC

OM

E

Results of multiple studies suggest that early palliative care improves quality of life. Temel et al. (2011) conducted a randomized control trial to examine the effects of early palliative care referrals for patients with metastatic stage NSCLC and to explore perceptions of prognosis and goals of care. Patients who were newly diagnosed with metastatic NSCLC received either early palliative care integrated with standard oncology care or standard oncology care alone. Of the 151 participants who enrolled in the study, one third of them reported that their cancer was curable at baseline, and a majority endorsed getting rid of all of cancer as a goal of therapy. The researchers discovered there was a substantial improvement in the patients’ understanding of prognosis and decision-making with early implementation of palliative care (Temel et al., 2011). In another study, Jacobsen et al. (2011) described a clinical practice that provided early palliative care consultation, which improved the quality of life, mood, and survival. There was a total of seven palliative care providers who made a consultation for 67 patients. The focus of the referral was symptom management, patient and family coping, and illness understanding and education (Jacobsen et al., 2011).

There is research that ref lects referral rates are compromised by physicians' concerns that patients and families would be alarmed about a referral to the SPC team. It is extremely important for the patient’s primary team to educate the patient and family on the role and benefit of having the support of the SPC team. There are misconceptions that a referral would mean that treatment was ineffective, that they must stop treatment, or that the patient is giving up. Some patients and families believe that a referral to palliative care is the same as a referral to hospice care.

The ability to focus on the patient as a whole is a primary focus of the SPC team, by not only utilizing the role of the provider, but also the chaplain, social worker, and other disciplines. The focus is not primarily on managing their physical but also spiritual distress, poor self-concept, and distress from their cancer diagnosis and prognosis. The chaplain on the team adds the expertise of identifying and addressing spiritual distress and suffering through history taking and assessment. Patients with advanced lung cancer often express feelings of emotional distress such as helplessness and hopelessness. The social worker on the team has a unique and instrumental role in addressing anxiety, fear, and depression of patients and loved ones dealing with lung cancer by providing additional support. They also work very closely with the discharge planner to help facilitate discharge planning. Providing oversight of the SPC team is the Nurse Navigator who identifies potential barriers and facilitates appropriate referrals for the team. Understanding the role of SPC is extremely important for nurses as they have the expertise to understand the complex needs of patients and families dealing with a lung cancer diagnosis and play an essential role to advocate for this vulnerable population.

In conclusion, the SPC team contributes to the patient’s quality of life through the use of a holistic approach which provide diverse capabilities of a supportive team with the mutual goal to exceed the expectation of patients

Supportive and Palliative Care in Lung Cancer continued from page 9 and families. The intention is not to replace the patient’s primary oncology team, but rather to add an extra layer of support. Nurses can provide education to patients and families about the role and benefit of SPC which will increase referral and decrease symptom burden in patients with lung cancer thereby improving their QOL.

ReferencesIyer, S., Roughley, A., Rider, A., & Taylor-Stokes, G. (2014). The symptom burden

of non-small cell lung cancer in the USA: A real-world cross-sectional study. Supportive Care in Cancer, 22(1), 181.

Jacobsen, J., Jackson, V., Dahlin, C., Greer, J., Perez-Cruz, P., Billings, J. A., Pirl, W., & Temel, J. (2011). Components of early outpatient palliative care consultation in patients with metastatic non-small cell lung cancer. Journal of Palliative Medicine, 14(4), 459-6.

Johnson, C. E., Girgis, A., Paul, C. L., & Currow, D. C. (2011). Palliative care referral practices and perceptions: The divide between metropolitan and non-metropolitan general practitioners. Palliative & Supportive Care, 9(2),181-9.

Temel, J. S., Greer, J. A., Admane, S., Gallagher, E. R., Jackson, V. A., Lynch, T. J., & Pirl, W. F. (2011). Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non–small-cell lung cancer: Results of a randomized study of early palliative care. Journal of Clinical Oncology, 29(17), 2319-2326.

World Health Organization (WHO). (2017). World Health Organization definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en/

November, December 2019, January 2020 DNA Reporter • Page 11

Web Join online. Visit us at www.denurses.org

Mail Delaware Nurses Association, 4765 Ogletown-Stanton Rd, Suite L10, Newark, Delaware 19713

Ways to PayAnnual Payment

Check Credit Card

If paying by credit card, would you like us to auto bill you annually?

Yes

Authorization Signatures

______________________________________________Monthly Electronic Deduction | Payment Authorization Signature*

______________________________________________Automatic Annual Credit Card | Payment Authorization Signature*

Monthly Payment Checking Account

Attach check for first month’s payment. Credit Card

*By signing the Monthly Electronic Payment Deduction Authorization, or the Automatic Annual Credit Card Payment Authorization, you are authorizing ANA to change the amount by giving the above signed thirty (30) days advance written notice. Above signed may cancel this authorization upon receipt by ANA of written notification of termination twenty (20) days prior to deduction date designated above. Membership will continue unless this notification is received. ANA will charge a $5 fee for any returned drafts or chargebacks. Full members must have been a member for six consecutive months or pay the full annual dues to be eligible for the ANCC certification discounts.

DNA Membership Activation Form

DNA is centrally billed through our national organization, the American Nurses Association. This means ANA manages the billing on behalf of the Delaware Nurses Association.

Monthly PaymentsYou can choose to pay your dues on a monthly basis – making your dues no more than your lunch out! ANA will either charge a credit card of your choice or deduct from your bank account 1/12 of your annual dues and any additional service fees. Bank accounts are debited on or about the 15th and credit cards are charged the first week of each month.

Annual PaymentsIf you choose to pay annually, you can pay by credit card or a check payable to ANA. If paying by credit, you also have the option to have ANA automatically bill your annual dues each month on your anniversary.

OnlineYou can join DNA instantly online. Visit DNA at www.denurses.org

Essential Information

First/MI/Last Name _____________________________________________ Credentials ____________________

Mailing Address Line 1 _________________________________ Highest level nursing degree earned ________

Mailing Address Line 2 ___________________________________________ Phone Number

Home _____________________

Work ______________________

City/State/Zip ________________________________________ Email Address __________________________

Professional Information

Employer ___________________________________________________

Current Position Title: (ie: staff nurse) ___________________________

Type of Work Setting: (ie: hospital) _____________________________

Practice Area: (ie: pediatrics) __________________________________

Currently Employment Status: (ie: full-time nurse) _________________

What is your primary role in nursing?

Advanced Practice Registered Nurse

Clinical Nurse/Staff Nurse

Nurse Manager/Nurse Executive

(including Director/CNO)

Nurse Educator or Professor

Not currently working in nursing

Other nursing position

Full DNA/ANA MembershipEmployed full-time/part-timeEnjoy discounts and participation at the state and national levelsPrice: $247/annually or $21.09/monthly, electronically

DNA State-Only MembershipEmployed full-time/part-timeEnjoy discounts and participation at the state levelPrice: $159/annually or $13.75/monthly, electronically

ANA National-Only MembershipEmployed full-time/part-timeEnjoy discounts and participation at the national levelPrice: $191/annually or $16.42/monthly, electronically

Reduced MembershipFull-time student, new graduate from basic nursing education program (within 6 months of graduation, first year only), 62 years or older not earning more than social security allows, not employedEnjoy discounts and participation at the state and national levelsPrice: $123.50/annually or $10.79/monthly, electronically

Special Membership62 years or older and not employedEnjoy discounts and participation at the state and national levelsPrice: $61.75/annually or $5.64/monthly, electronically

Dual MembershipRN holding membership in ANA through another state; proof of membership is requiredEnjoy discounts and participation at the state and national levelsPrice: $101/annually or $8.92/monthly, electronically

Select Which Membership is Right for You Choose the way to pay that’s right for you!

Welcome New & Returning Members

June Campbell BearAdeline Cheyson NewarkGayla Cragg North East, MDNicole Cruz TownsendVictoria Deputy WilmingtonJennifer Dunford HockessinCharles Evans Jr WilmingtonAndrea Forsyth LewesRay Fulkrod DagsboroCheryl Gamble New CastleMichelle Gibson NewarkStephanie Gonzalez NewarkDarralyn Hall WilmingtonDavid Hancox WilmingtonMelanie Hiester NewarkLisa Ignudo NewarkElizabeth Intermoia TownsendPamela Kaplan LewesMary Ann Luft NewarkMonica Matthews MagnoliaMarykate McGurk NewarkErica McPhail MilfordRita Meadows MilfordLaura Mills MilfordRhonda Montgomery TownsendJackline Nanga-Nsemwa BearBonnie Osgood NewarkEsther Oteng NewarkKatelyn Petz WilmingtonKimberly Purcell New CastleTori Sabbatini NewarkRenee Smith WilmingtonTerrence Stephen NewarkBerline Sylvain SmyrnaLisa Wallace WilmingtonElizabeth Walls NewarkKelly Watkins WilmingtonRebecca Wilson Georgetown

To access electronic copies of the DNA Reporter, please visit

http://www.nursingald.com/publications