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Whats New in Psycho-Oncology?!

Presented by: Barb Henry, MSN, APRN-BC

Melvin Gale, MD & Associates

ONS Psychosocial Needs Project Background

The number of people touched personally by cancer continues to grow. Therefore, people experiencing emotional distress in need of psychosocial support has increased. The Institute of Medicine (IOM) published recommendations for psychosocial care in its 2007 report - Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs.

Psychosocial Education Team

Formed by six ONS members representing different geographical areas, various years of experience, diverse educational

backgrounds and clinical practice. First meeting in Pittsburgh in

2010 followed by multiple email & phone planning conferences .

Fulcher & Henry wrote content for a web course curriculum that

was finalized with input from the rest of the team.

The team goal is to help oncology nurses emphasize psychosocial

assessment, interventions, follow-up, education, and program

development in their own practice and within oncology clinical

settings beginning in the year 2011.

Education Timeline

Nov.-Dec. 2010- Web Course offered Jan. 2011- Promotion of 2011-Year of Psychosocial Care in ONS Connect and
via email blast to Chapter Presidents

Feb. 2011- ONS Connect article Screening for Distress in Patients with Cancer
by Caryl Fulcher & Tracy Gosselin

May 2011- Web Course offered; ONS Connect article with focus on Anxiety and
Depression by Barb Henry & Congress Poster summarizing the project by Carol Tringali

June 2011- ONS Connect article Role of the Psychiatric CNS and NP featuring
ONS Members in these roles

Aug. 2011- Web Course offered Nov. 2011- Web Course offered Dec. 2011- ONS Connect Article on Self Care for Oncology Nurses by Laurl
Matey & Tracy (Skripac) Kastenhuber

Web Course: Integrating Psychosocial Care into Oncology Practice

This is a faculty-led course, with facilitated discussion postings, interactive learning activities, and a post-test, that addresses cultural, spiritual, and caregiver issues, along with care implications related to cognitive dysfunction, anxiety, depression, fatigue, sexual alterations, and sleep disturbances. Offered November 2010 and February 2011 (45 participants). Future course offerings in May, August, and November 2011. Receive 8.5 CNE Cost $69 for members $100 for nonmembers Register via:

Other Initiatives
Hot Topic Chats Featured articles throughout the year in:
CJON & ONF ONS Connect

Invitation to Chapter Presidents & all members to:

Initiate/promote use of psychosocial assessment tools during patient evaluation.

Conduct research, EBP, and QI projects in their practice area. Share knowledge with colleagues through Chapter meetings and program development.

Assessment Tool

Psychosocial Articles
38 so far in 2011 117 in 2010

Determinants of Quality of Life in Patients Near the End of Life: A Longitudinal Perspective CJON 1-11 A Pilot Study of Activity Engagement in the First Six Months After Stem Cell Transplantation ONF 1/11 Mindfulness-Based Stress Reduction Among Breast Cancer Survivors: A Literature Review and Discussion ONF 3/11 The Power of Videotaped Personal Statements of Patients With Lung Cancer: A Recruitment Strategy for Smoking Prevention and Cessation Programs ONF 1-11

Cancer & Severe Mental Disorders-CJON Mentorship Writing Project article coming in 2011 or 2012 by Thomas & Henry

Psychosocial CJON Column Heart of Oncology Nursing

Shared Inspiration

(Malloris story 8-2009) (The Window Watcher by Mary

Lives Embraced Through Memories

Murphy 4/10)

Nurse as Writer, Writer as Nurse

4/2011 12/2008 (about Randy Pausch) (chemo plant quilts)

Inspiration From The Last Lecture

Healing With an Artistic Touch 10/2008

Memoirs Inspire Effort to Eradicate Human Papillomavirus

12/2009 (about Kristen Forbes family Noblesville IN)

Cast Away With Cancer

4/2009 (Katherine Wilson, UNC)

The Window Watcher The window watcher watches her wonder world below The window world from which she forever waits Her horizontal throne the deathbed near a small window pane. She views her kingdom below with new eyes Former walker of the streets she sees her customers with intrigue Her past view of the world has been through eyeglasses of deceit. Her kingdom spans city blocks and miles of seasonal delights Figures moving, working and whispering unheard sounds She sees them now as she has not before. Seasons become her view, season viewing consumes her life

Winter winds lick the panes, snowflakes dance to a Christmas tune

Spring flowers, and green grass and signs of life.

Summer sounds, laughter, children biking, hot dog carts, crisp flags snapping to a breeze
Fall leaves rustle, pumpkins about, trick or treaters and candy-filled bags And winter comes back around and comes back around. The window watcher watches no more The window now empty, a faded vision remains The window watcher watches though her new window from above. Mary Murphy, dedicated to Jillian

Other Initiatives-The Cancer Journey Traveling Companions Blog

Prevalence of Mental Health Issues

20-40% of people with cancer have significant psychosocial distress, but less than 10% of these people actually are identified and referred for help

NCCN, 2010

Top Ten Common Mental Health Concerns in Cancer Care

Depression Suicide Anxiety/PTSD Fatigue/Sleep Disturbance Cognitive Changes Spirituality Sexuality Tobacco Use Caregiver Strain/Burden-Family Issues Cultural Issues

Prevalence of Depression

The incidence of depression ranges from 13% to more than 50%; most frequently cited is an incidence of ~25%.

There are many non-psychological causes of depression in the patient with cancer:

Cytokine production may be affected by tissue destruction and inflammatory processes (Bowers, 2003) (CYP450 potential for psych/chemo drug interations) Tumor involvement of the CNS Metabolic disturbances

Medications including analgesics, anticonvulsants, antihistamines, hormonal agents, sedatives, steroids, and antineoplastic agents, among others.
Fulcher & Henry, 2009

Prevalence of Suicide
Risk of suicide in people with cancer is twice that of the general population, and higher suicide rates have been found in males, whites, unmarried individuals, and those at an older age when diagnosed (Misono, 2008). Additional risk factors:

Depressed mood, hopelessness Specific plan for suicide and its lethality Pre-existing psychopathology Poor prognosis or advanced disease state Delirium and disinhibition Uncontrolled pain Intolerable fatigue Drug or alcohol abuse Helplessness, loss of control, and impulsivity Individual or family history of suicide. (Miller and Massie, 2006)

Prevalence of Anxiety
Prevalence estimates of pathological anxiety, (requiring medication and/or psychotherapy), in cancer vary greatly, with rates of 30% or more Cancer-related anxiety increases in the following situations: initial diagnosis anticipation of check ups diagnostic studies that might detect recurrence with advancing disease news of poor prognosis at the end of active treatment or when surveillance intervals are increased

Valentine, 2006

Sleep Disturbances

It is estimated that 45% of people with cancer experience sleep disturbance. This is about 3x that of the general population.

Caregivers also experience sleep disturbance

Insomnia is the most common sleep disturbance; it is defined as a disorder of initiating and maintaining sleep. NCI Sleep Disorders PDQ, (2010)

Prevalence of Fatigue

Fatigue is the most commonly reported symptom of patients receiving cancer treatment (which came firstfatigue or depression?) Incidence estimated at 80%-100%

Fatigue may continue for years post treatment

It may occur as a single symptom or in a cluster As a subjective symptom, fatigue is best assessed by self-report.
Mitchell, 2009, ONS, PEP

***Which came first-fatigue, anxiety, or depression?...

Sexuality Issues
Erectile Dysfunction Decreased Libido Urinary Incontinence Bowel Dysfunction Fatigue Birth Control Vaginal Dryness/Stenosis Pain Anemia Muscle Loss Body Image Changes Relationship Difficulties

Hughes, 2010 & Molly Brixey 2011-Cancer & Sex-Can We Talk?

Tobacco Use/Nicotine Dependence

Prevalence of ever smoking is highest among patients with tobacco-related cancers 90%-lung cancer 80%-head and neck cancer

20-50% of patients with cancer continue to smoke after diagnosis

A large proportion of patients who quit smoking will relapse after completing their treatment 5% or less who quit without help, (from a program or medication), will remain smoke-free

Caregiver Strain & Burden

Caregivers also experience significant distress and deserve attention from oncology nurses.

Caregiver strain: perceived difficulty in performing the caregiver role

Caregiver burden: alterations in caregivers emotional & physical health that can occur when care demands outweigh available resources
Honea, et al, 2009

Common Psychiatric Medications Used in Oncology-Antidepressants

SSRIs- citalopram (Celexa), escitalopram (Lexapro), fluoxetine

(Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft)

SNRIs- desvenlafaxine (Pristiq), duloxetine (Cymbalta), venlafaxine

(Effexor) , atomoxetine, (Strattera)

Others- mirtazapine (Remeron), nefazedone (Serzone), trazodone

(Oleptro), buproprion (Wellbutrin)

Tricyclics- amitriptyline (Elavil), doxepin (Sinequan), nortriptyline

(Pamelor), protriptylene (Vivactil), chlomipramine (Anafranil), imipramine (Tofranil), desipramine (Norpramin), trimipramine (Surmontil)

MAOIs- isocaboxazid (Marplan), phenezine (Nardil), seligiline

(Emsam), tranylcypromine (Parnate)

Common Psychiatric Medications Used in Oncology

Anti-anxiety Agents
Lorazepam (Ativan)
Clonazepam (Klonopin) Alprazolam (Xanax)

Diazepam (Valium)
Oxazepam (Serax) Chlordiazepoxide (Librium) Buspirone (Buspar) (non-benzodiazepine anxiolytic)

Off labelPropranolol (Inderal) (beta blocker) Hydroxazine (Vistaril or Atarax)

Diphenhydramine (Benadryl)

Common Psychiatric Medications Used in Oncology

Sleep Aids
Zolpidem (Ambien)
Flurazepam (Dalmane) Temazepam (Restoril)

Triazolam (Halcion)
Eszoplicone (Lunesta) Ramelteon (Rozeram) Zaleplon (Sonata) Estazolam (Prosom)

Secobarbital (Seconal)
Chloral Hydrate

Off label-any of the meds from the anti-anxiety and antidepressant slides as well as some low dose antipsychotics

Less Common Psychiatric Medications Used in Oncology


Atypicals/2nd or 3rd Generation- aripiprazole (Abilify), asenopine (Saphris), clozapine (Clozaril), iloperidine (Fanapt), lurasidone (Latuda), olanzapine (Zyprexa), paliperidone (Invega), quetiapine (Seroquel), risperidone (Risperdol), ziprasidone (Geodon) 1st Generation- chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), loxapine (Loxitane), prochlorperazine (Compazine), thioridizine (Mellaril), thiothixene (Navane), trifluoperizine (Stelazine)

Less Common Psychiatric Medications Used in Oncology

Mood Stabilizers/Bipolar Drugs

Valproic acid (Depakote)

Carbemazepine (Tegretol) Lamotrigine (Lamictal) Lithium (Lithobid, Eskalith) Oxycarbemazepine (Trileptal)

Atypical antipsychotics

Less Common Psychiatric Medications Used in Oncology

Stimulants/ADD Medications
Dextroamphetamine (Adderall, Dexadrine) Methylphenidate (Concerta, Desoxin, Ritalin, Metadate, Methylin) Methylphenidate transdermal (Daytrana) Dexmethylphenidate (Focalin) Guanfacine (Intuniv) Dexedrine (ProCentra) Lisdexamphetamine (Vyvanse)

Clonidine (Catapres, Kapvay) Atomoxine (Strattera)

Less Common Psychiatric Medications Used in Oncology

Erectile Dysfunction Medications

Tadalafil (Cialis) Vardenifil (Levitra) Sildenifil (Viagra) Yohimbine (Yocon) Alprostadil urethral-injection,

transurethral, (Muse, Edex, Caverject)

References /108/pdf/References.pdf
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