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Lynne, I didn’t even know we had/ offered The James Cancer Exercise Program! Is this a new resource available to our patients or limited to certain patients?
Greg- I would agree it is definitely something we don’t see a whole lot (other than the prostate population and assessing for hot flashes) but the extensive list of side effects could potentially hinder actually completing treatment.
Mindy Blackwell
gyn/onc Mill RunWhat was the knowledge gained from the article? Serum Vitamin D can be preventative in side effects/symptoms. I have known how beneficial high amounts of Vitamin D is for our overall health but I never thought about how much more beneficial it could be if we were to utilize it in our patient care and their symptoms.
Will the research/information in this article change or influence your practice? Yes If so how? I will be more bold in recommending vitamin D and the other non pharm treatments for symptoms to my patients.
What other questions does the article raise about current practice? Why are we not recommending vitamin D and other natural supplements more often when they are proven over and over to be beneficial in more than just one area. We need cholesterol and sunshine to make our own vitamin D but this is never talked about with out patients. Why are we not in general talking more about natural ways of managing symptoms instead of constantly just writing a prescription and then we have more side effects to manage and get another prescription with more side effects and it is just a never ending cascade.
We are not even talking to our patients about how harmful processed foods/artificial dyes/carbs/sugars/syrups are for our metabolic health.
Do you agree/disagree with the conclusions of the author, why?I do agree that many of the universal treatments for AIMSS are easily accessible so providers need to be aware of them so they can be used in their care plans. I think they are so hype focused on their chemo plans that they don’t take the time to learn about anything that my compliment the treatment or the management of side effects.
Lynn – Cancer: Precautions for Use of Dietary/Herbal Supplements just discourages the use of anything not a prescription. A deep dive into naturals will show that most studies that discourage the use are financed by those that would lose profits if people started using naturals vs prescriptions. It is all about money unfortunately.Jeff – a deep dive into vitamin D and its benefits and safe amounts would show that amounts higher than the FDA’s RDA’s are actully safe and beneficial. The downside of taking high doses of vitamin D and really benefitting metabolically is that we would need less prescriptions. Looking at CEO’s of the drug companies and those that sit on the boards of the departments making the recommendations are all intertwined – it is all about money. We need cholesterol and sunshine to make vitamin D – exactly what we are told to not have!
Everyone – when it comes to naturals we need to unlearn and rethink. There is a whole world of things that promote health and quality of life that we are not utilizing.
Hi everyone. I appreciate Lynne Brophy picking this topic and starting this interesting discussion. My name is Beth Harding. I am new to oncology and interested in learning as much as I can about various cancers and their treatments. I work on the infusion unit at 5 James. Most breast cancer patients get their infusions at Stephanie Spielman, but because we are open on weekends and holidays, breast cancer patients do come to our unit for infusions.
I gained knowledge about aromatase inhibitors (AI’s). Some of the common AI’s are: Arimidex, Femara, and Aromasin. These are an important therapy utilized in breast cancer patients. One of the many negative side effects of these medications are arthralgias. This is referred to as “Aromatase Inhibitor-associated musculoskeletal syndrome” or AIMSS. Experiencing severe joint pain causes patients to discontinue therapy, therefore increasing risk of breast cancer relapse and mortality.
Implement in practice: Learning about the side effects of different medications that our patients are taking can lead to a better understanding of topics to discuss while assessing patients. These articles reinforce how important it is, not only to discuss our patient’s symptoms, but also encourage them to talk to their oncologists, PCP’s, and/or palliative medicine providers to give them options of treating negative side effects, thus making them more comfortable and improving their quality of life.
I agree with the conclusion of the articles. I have found that many patients are not great historians of their problems, symptoms, and difficulties while going through cancer and all that it entails. The healthcare team only has a certain amount of time to gather and give information to them. The more we learn to combat the problems they are likely experiencing, our time can be best utilized to make the biggest positive impact for our patients.Lynne,
I appreciate the information you passed on about Dr. Alexa Meara, Rheumatologist, and the James Exercise Program. I’m interested in looking up more information on both of those topics and discussing further with my fellow nurses and providers that I work with. There are various resources we can utilize and the more we have in our tool box, the better outcome our patient’s will have. Exercise affects us positively in many ways, and referring our patients to a program will help motivate and guide them.@Patti, Greg, and Lynne: I enjoyed reading your posts, especially the information about the different treatment modalities for AIMSS. Maintaining a healthy weight is super important and eating a healthy diet of fish, chicken, fruits, and, vegetables is important, specifically if you are suffering from arthralgia. Taking supplements such as glucosamine, chondroitin, or vitamin B12 can potentially improve joint pain too. Also, low impact exercise such as: walking, yoga, and swimming are great alternatives to other forms of exercise that may exacerbate symptoms.
There is so much information in the articles, that reading others’ posts helps to organize it in my own mind, in order to present the information to the patient. Thanks!I am intrigued by the healthy discussion regarding vitamin D supplements. I know my vitamin D levels in the past have been borderline low, and I discussed this with my primary care physician. I am taking a supplement that has low dose vit D included and I was concerned about taking too much. My doctor said it is actually hard to get an elevated vitamin D level. Patients with low levels of vitamin D will get prescription-strength supplements and even then their levels only increase slightly. Obviously this is something that each person would have to discuss with their own physician based on their specific circumstances, but I found his reply interesting.
Lynn- thanks for all the helpful information! Like others have said, I was not aware of referrals to the James Cancer Exercise program or Dr. Alex Meara. I think it is wonderful that the James offers exercise and healthy eating programs- but I wonder how much they are utilized as many of us are unaware of them. I know similar programs are offered to staff through Your Plan 4 Health. Has anyone ever taken any classes/programs through YP4H?
Ok, now I have heartburn over Greg’s concern that it is a game of whack-a-mole to recommend interventions for our patients. I understand. Let me clarify friends. It is always tricky to pick just two articles for a journal club. I do not always get the chance to share all the good articles on non-pharmacologic interventions nurses can recommend to patients. In an article in a very fine journal, JCO, the authors summarized what we know to be effective for treating AIMSS. This article is available here: FW: https://youtu.be/BtmtwuJzVJ8?si=SpnIkGaAYD7PvS5f or look up: Gupta A, Henry NL, Loprinzi CL. Management of Aromatase Inhibitor-Induced Musculoskeletal Symptoms. JCO Oncol Pract. 2020;16(11):733-739. doi:10.1200/OP.20.00113.
What we know works much of the time: Exercise (and in particular moving in a warm water pool at the gym or YMCA), yoga, acupuncture, Duloxetine
Here is what might work: Switching to another AI, eating more fish rich in Omega 3 fatty acids (salmon, tuna, cod, mackeral, sardines, herring, lake trout)
Patti and Greg, thank you for joining us. Could you offer two risk factors that cancer patients can have for AIMSS?
It so great to learn about your response to these articles!
Lynne Brophy-
The article by Baumrucker and Grigorian (2022) states that risk factors for AIMSS include less than 5 years from menopause, history of taxane-based chemotherapy, obesity and past medical history of arthritis or osteoporosis.Hello! My name is Wil and I am a newer Oncology Nurse. I work in the James pre-op department.
1: What was the knowledge gained from the article?
Being a newer oncology nurse, I do not always recognize the numerous medications our patient population is on. Looking into the drug class of aromatase inhibitors I realized that I see many of these medications on a daily basis during chart review. I learned that this specific class of medications has numerous side effects included musculoskeletal pain. The medication duloxetine which is often seen in my patient’s medication list is one of the recognized treatments for AI side effects. The correlation between these two medications is a new realization for me. I also can imagine that a lot of these side effects can be over looked as in Lynne’s family members case.2:Will the research/information in this article change or influence your practice? If so how?
If the information in these articles influences my practice it would unfortunately be small. As a preoperative nurse I only deal with initial patient assessments and a quick medication review. However, with the new information I have gained it is likely that I could correlate some of these medications and patient’s self-reported pain. Even though my time with them is brief I may be able to recommend certain non-pharmacological pain interventions as discussed in these articles. This instance might be uncommon but even if it helps one patient then this journal club would have been a success!3:What other questions does the article raise about current practice?
In the information it was discussed that there is no practice guidelines for how to treat aromatase inhibitor side effects. This is alarming as it is a common drug class of medication prescribed. It raises the question on what other common medications are we missing guidelines on and how many patients are missing standardized care?4:Do you agree/disagree with the conclusions of the author, why?
I do agree with the conclusions of the author. They called for more research and studies which is one of the foundations for evidence based practice. In order to create a practice guideline there will have to be substantial research in place.Greg, I also did not put much thought into this drug class and their medications. As a preoperative nurse I have not given these medications as they take them at home. I also noticed that the two articles had some conflicting information on treatments such as Vitamin D. This is one reason I agree with the articles conclusion that more research is needed!
Reena, I like that you are interested in seeing more research on alternative therapies rather than pharmacological. Often times these patients are already taking numerous medications and adding an additional might not be the best option. This additional medication whether it be duloxetine or another may come with its own side effects.
Hi everyone, this is an informative discussion this month. Lynne, you need to join us every month!
I didn’t know about some of these resources either and I have been here forever.Jeff, I saw your question to Lynne about the exercise program. It has been around for a bit, but I think we need to remember it to offer to patients. The PT and OT departments at SSCBC have recently come to both staff meetings and our breast med onc work group to speak with providers. They do an amazing job! I will say, though, that many patients are reluctant to have another appt or worry it will make their pain worse. Although we know that our PT dept will meet them where they are at, i do think we need to make sure to be re-iterating this to patients.
Lynne and Patti, I do find our supplement handout very helpful and we do try and encourage patients to reach out to discuss any supplements, esp during chemo class and at new patient appts. In my experience, we do have quite a few patients who have tried glucosamine, but do not see big improvement in their arthralgias. We do try and encourage it though as a safe supplement to try!
Hello my name is Kelly Harms. I am a nurse in CTU.
1. The knowledge I gained from these articles was just the fact that these drugs cause this side effect in general, which happens in a big percentage of the patients that take them. In the first article, it stated 50% report a new onset or worsening of joint pain.
2. I can’t say it is going to change my practice in anyway as we don’t have many or any patients that are on these drugs. However, it will make more more aware if I do have someone on a AI to be more mindful in asking bout if they have joint pain present.
3. Both articles mentioned acupuncture was reported as helping arthralgia, which made me want to explore acupuncture more. I really don’t know much about it, of course I’ve heard about it helping different things, but don’t really know the mechanism as to why. Has anyone here every tried it for anything, just curious.
4. I did find the articles contradicting each other about Vitamin D supplement. The first articles stated there were benefits of this supplement while the second article stated there was no association with improvement of symptoms. Did anyone else notice this?
Lynne-I noticed you were asking about referring to PT for an exercise program. I think this would be a good route because I was thinking to myself it would be hard to motivate yourself to exercise if you are experience joint pain.
Greg-I agree with you on the interventions being mixed reviews on what works best to really help. Lynne, what ended up working best for your mom?
Hi all! DeAnna here, working in after hours triage.
1) What was knowledge gained from these articles?
I learned many knew things with this topic. I learned about the significant joint pain that is induced, possible correlation of menses as well as menopause might increase symptoms, along with increased osteoporosis (although it makes sense). I was shocked at the high incidence of patience stopping medication, upwards of 50%, because of the side effects. That is a huge number! Vitamin supplements make sense to help combat the side effects, but the large dosage was a shock to me.2) Will the research/ information change/ influence practice?
I don’t know that it completely changes my practice, but it gives me a heighten awareness when patients call in with side effects and how I can try to help in the short term until their clinic is open and can talk more about further options.3) What other questions do you have from reading the articles?
Could we just go ahead and add in supplements or medications to help these patients if we know the high incidence of stopping a medication because of the side effects.4) Do you agree/ disagree with authors and why?
I agree that we should be looking at the side effects and trying to be pro-active so that patients can stay on treatment for less chance of stopping therefore giving higher chance of cancer coming back.
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