[shalvoy.1]

Welcome to our September 2022 journal club.
This month Michelle Callihan has offered to be our lead. Thank you Michelle!
She has found two articles describing non-pharmaceutical treatments for chemotherapy side effects.

The first article describes a research project done by members of our James team.
I am looking forward to our discussion on these topics.

Efficacy of Inhaled Essential Oil Use on Selected Symptoms Affecting Quality of Life in Patients With Cancer Receiving Infusion Therapies

Effectiveness, Safety, and Tolerance of Scalp Cooling for Chemotherapy-Induced Alopecia

[callihan.9]

Thank you for reading the articles. I am a nurse in the Ambulatory JCRU.

1. Efficacy of Inhaled Essential Oil Use on Selected Symptoms Affecting Quality of Life in Patients with Cancer Receiving Infusion therapy.

I want to congratulate our Morehouse Infusion team for getting published. I remember this trial and all the hard work they put into it.

What was the knowledge gained from the article?
I remember some patients totally disliking some of the scents. The article states that ginger effected fatigue and anxiety but did not effect a patient’s nausea. The bergamot did not have a significant impact on anxiety not did the chamomile. The study thought maybe those findings were due to the pre-medications given to the patients did such a good job of controlling side effects.
I think once you find the right combination of an essential oil(s) to help with your side effect it makes a world of difference. And it is not another pharmaceutical we are throwing at the patient. The article states that essential oils have little to no side effects while pharmaceutical can add to the side effects (ex. zofran for nausea causes constipation). The article talks about just a small amount went along way, 7 drops on a cotton ball or a squeeze of a bottle just to inhale the aroma from the 3 ounces of essential oil in the container.

Will the research/information in this article change or influence your practice? If so how?
I have noticed since this trial we have stopped using essential oils in are infusion clinics. I have really dropped the ball in suggesting it. I will go back to talking to the patients about essential oils and using them from the resource bag in the clinic.

Do you agree/disagree with the conclusions of the author, why?
I completely agree with the authors of this journal. Essential oil is very helpful in many ways to our patients and their side effects to their treatment.

2. Effectiveness, Safety and Tolerance of Scalp Cooling for Chemotherapy-induced Alopecia

What was the knowledge gained from the article?
I always find it intriguing when I go to the Breast Centers chemotherapy clinic and see the cool caps. I have helped put one on & it did not look comfortable at all. It also makes the patient very cold and most of the times they are wrapped in warm blankets and still shivering.
I know that hair is related to a person’s general well being and the way they see themselves. Cancer is a devastating journey to have to go through and to some losing their hair just puts them right out there in the spotlight. The article reminds me that if your self esteem is low, you are more depressed and anxious which doesn’t help in your treatment. Depression and anxiety have been linked to more side effects such as nausea and fatigue.

What other questions does the article raise about current practice?
I know we use cool caps on our breast cancer survivors but why don’t we give our other Adriamycin patients the option? The article tells us insurance companies do not like to pay for the cool caps. I would have to think insurance companies lump it under “cosmetic”. But if you help a patient feel better about themselves, then they have less anxiety and depression which could cut down on the side effects. Which could cut down on all the medications being prescribed to the patient. Sounds like a “proactive” approach to healthcare… hmmmmmm
What about cold therapy for neuropathy? Like ice socks or ice gloves? I know several patients at the Breast Center put ice on their feet & hands during their treatment to help with the neuropathy. I am curious if the Mill Run Chemo Clinic has any patients that do this for their treatment.

Do you agree/disagree with the conclusions of the author, why?
I do agree with the article when it says there is a lack of guideline recommendations of the use of scalp cooling to prevent alopecia. There are no set guidelines for what the temperature should be set at, how long the cooling time is before chemotherapy and after chemotherapy. The ranges of cooling is “5-50 minutes prior to chemotherapy” and “15 minutes – 4 hours after chemotherapy”. To me this is a HUGE range and would make you think if you did not do it long enough you could still experience alopecia. The temperature guideline do not really give you a set number either. I know at the Breast Center they have a standard that they received from the manufacturer.

[shaffer.641]

Efficacy of Inhaled Essential Oil Use on Selected Symptoms Affecting Quality of Life in Patients with Cancer Receiving Infusion therapy.
1: What was the knowledge gained from the article?
This study must have been difficulty to initiate. Most patients are skeptical of essential oils. I would never think to use Ginger for anxiety/fatigue. I have always know for it to help with nausea/upset stomach. I also never thought of almond as an essential oil.
2: Will the research/information in this article change or influence your practice? If so how?
Not really, I don’t normally recommend essential oils to patients as there isn’t a ton of research that I’ve seen. I wish there was more research so that it could be something we initiate in our practice. We are so quick to prescribe a medication without thinking of other ways to help with symptom management.
3: Do you agree/disagree with the conclusions of the author, why?
I agree that perhaps some of the low symptom burden was due to SOC symptom management that were already being implicated.

Effectiveness, Safety and Tolerance of Scalp Cooling for Chemotherapy-induced Alopecia
1: What was the knowledge gained from the article?
I’ve seen CIA as a reason for patients to not get chemotherapy, or at least the chemotherapy that will work best. It’s one of the only external side effect of treatment and lets the world know you’re sick. I didn’t know breast cancer patients were the highest to use scalp cooling, but it makes sense. I’d be interested to see how that compares to GYN patients. I also found it interesting that those undergoing scalp cooling reported WORSE QOL, mainly due to uncertainty of hair loss or disappointment with affectiveness.
2: Will the research/information in this article change or influence your practice? If so how?
I think providers should speak with patients more about this when talking about chemotherapy. If a patient hesitates on a regimen d/t CIA, providers and chemo nurses should mention scalp cooling as an option.
3: Do you agree/disagree with the conclusions of the author, why?
I agree that future research should be done on how to improve tolerance to the cold temperatures. Having something that cold on your scalp can be unpleasant.

[goodman.100]

1. What was the knowledge gained from the article?
Complementary and alternative medicine (CAM) is a buzzword right now, so it was good to see someone applying it to evidence-based studies. I found it surprising that Williams, et al (2022) did not find more significant results with aromatherapy. It’s unfortunate that Covid interrupted their study. It will be interesting to see if anyone studies this subject further. Scalp cooling is utilized at the Stephanie Spielman Comprehensive Breast Center infusion unit to decrease incidence of chemotherapy induced alopecia (CIA). It was reassuring to read that Zhang, et al (2022) found the evidence supports its continued use, and that it significantly reduces rates of CIA.

2. Will the research/information in this article change or influence your practice? If so how?
Because the authors of the aromatherapy study did not find any strong results, I don’t think it will change my practice at this time. If future studies demonstrate further results, I would consider a practice change then. For patients that use essential oils or other CAM’s with benefit, I will recommend they continue. As far as scalp cooling is concerned, I am not involved with it so it will not change my practice. I would be happy to share the article with my colleagues at the Breast Center.

3. What other questions does the article raise about current practice?
What other aromatherapy treatments are available that weren’t tested by Williams, et al, (2022) both in different scents and different applications? I had a positive experience with topically applied essential oils several years ago when I had a migraine and didn’t have my normal medication with me. Another nurse had an essential oils kit she kept in her locker and offered to help with my migraine. I was willing to try anything at that point, so she put some peppermint oil on a cotton ball and put a dab on each of my temples. My migraine disappeared in minutes- it was like magic! I did not have any previous experience with CAM, so I was surprised by how much it helped.
I also find it interesting that, here at the James, scalp cooling is only offered at the Breast Center. Many other patients receive CIA agents and are not offered any interventions. I hope that articles such as the one by Zhang, et al (2022) help expand scalp cooling to more patient populations.

Williams, A. S., Dove, J., Krock, J., Strauss, C. M., Panda, S., Sinnott, L. T., & Rettig, A. E. (2022). Efficacy of inhaled essential oil use on selected symptoms affecting quality of life in patients with cancer receiving infusion therapies. ONF 2022, 49(4), 349-358. DOI: 10.1188/22.ONF.349-358

Zhang, X., Yang, K., Liu, W., Huang, J., Ning, N. (2022). Effectiveness, Safety, and Tolerance of Scalp Cooling for Chemotherapy-Induced Alopecia. ONF 2022, 49(4), 369-384. DOI: 10.1188/22.ONF.369-384

[harms.28]

1. I had no idea that Martha Morehouse did a research project and published their findings! That is awesome. I will be completely honest, I’ve always been skeptical of essential oils and if they actually work. It was very interesting to see the conclusion that ginger did indeed have a positive impact for fatigue and anxiety. I also liked how they included and gave credit to the standard of care methods in this article as well.

2. A question I had from the scalp cooling article, if scalp cooling has been used since the 1970’s, how have there not been more well-designed trials by now? I found that really unbelievable.

3. Unfortunately, my unit would not come across an opportunity to use the scalp cooling caps, so I won’t be changing my practice based on the article. Working in clinical trials, which can be very specific, it would be interesting to see if any of the sponsors have any issues with using essential oils. I have never heard of it being contraindicated, but it’s not something we necessarily have thought about here.

[harms.28]

I forgot to say this in my first response. My name is Kelly and I work in CTU.

Michelle- I agree with you on the no standards for cooling caps. It almost seemed like patient preference on how long before and after when I would work at Mill Run, or maybe I just didn’t know enough about the process.

Greg- That’s funny you mentioned trying essential oils for your headache and it worked like magic. I guess maybe I’ve always been skeptical because it’s usually someone trying to sell me on them. But, you got to try it money-pressure free and it worked!

[burk.109]

Megan Burk and I work at SSCBC Infusion

1.What was the knowledge gained from this article?
a.Essential oils are such an interesting topic. I feel like from personal experience patients either are very interested in the use of them or have no interest at all. As mentioned I find it quite interesting that Ginger was used with success for anxiety and fatigue. I do think having a study conducted in house will also help nurses present the options when conducting teaching.
2.Will the research/knowledge change your practice?
a.I do feel like this article helps improve my knowledge of essential oils. Showing the use of ginger and bergamot with success will help provide other options to patients besides the typical lavender use.
3.Questions about current practice?
a.In regards to the scalp cooling— I do work at SSCBC so this is common practice for our patients to use. Being that we treat majority women I do agree that the body image is a big thing for woman, particularly when you lose your hair. I question why this is not being offered to other disease lines throughout the James though. We have heard that this was going to start being covered by insurances and when that happens I have a feeling we will start seeing more patients inquiring about the use. I question space issues and time. This is time consuming and takes up a lot of chair space. I do understand the efficacy and want for patients but I do think there will need to be a change in the way it is implemented to help with turnover especially when it becomes less costly and more participate.

[burk.109]

Kelly– It is interesting you say that about that scalp coolings and no well designed trials. From my understanding, there are only two companies that are really involved in scalp cooling, maybe more but there are two that used most frequently. At the breast center it has been determined that is the patient responsibility to do all the pre and post care related to the scalp cooling. We simply house the machines that are used. Now, we do help some and they are sized by MED ONC before starting but again as I said in my post unfortunately it comes down to time and you khow how that can be. I do think there should be more done to make this simpler for the patient and staff.

[burk.109]

Greg–I too have had great success with pepermint and have patients report the same. I would be interested to see a study with more oils used and what that looks like.

[goodman.100]

Megan- It’s good to hear that scalp cooling therapy might be covered by insurance soon. But I also have questions about time and space. Most infusion clinics are already short on space and staff are short on time. I don’t see how they would be able to add scalp cooling to any unit other than SSCBC infusion. I wonder if the infusion units in the new building will have room to add scalp cooling? I remember floating to your unit and, thankfully, the patients seemed to know the process and handled it mostly on their own. Of course, that is because they were already several infusions into their treatment. I imagine the education on the 1st couple of treatments take a considerable amount of time.

[goodman.100]

Michelle- I also remember seeing patients at the breast center wear cooling/ice gloves and socks with their infusion. This, of course, was something they brought from home and did themselves- it was not offered by clinic staff. But it does beg the question- should more patients do this? Is it effective? For something like oxaliplatin it would make neuropathy worse! They are so many different interventions that need to be studied!

[shawver.25]

Thanks for leading this discussion Michelle! I am Jeff and work in ambulatory JCRU as well.

What was the knowledge gained from the article?
Both of these articles offered good insight into alternatives to medications. Every new medication that comes out has a list of side effects a mile and a half long. Offering non-pharmaceutical options to our patients would be great (providing the treatments work.) I found it interesting that ginger was found to be effective with fatigue/ anxiety but not helpful with nausea. Ginger (and ginger ale) is marketed to help with upset stomach and nausea. I can also believe that the scents of some of these could be rough for patients. I’ve had a few patients address being sensitive to smells and tastes while undergoing chemotherapy (especially Folfox/Folfiri which a good number of the patients in this trial would have received- my initial thought is they have smell aversion due to increased nausea but unsure exactly).

As for the scalp cooling- I thought it was interesting that it’s been around or common for 40+ years and no real ground breaking trials have been completed on it. I have seen patients buy cold gloves/ socks/ caps and bring them to treatment at various locations- even for drugs with normally gentle side effects.

Will the research/information in this article change or influence your practice? If so how?
These articles will make me think harder about adding these suggestions to our patients. In the last 15-20 years there have been numerous advancements in medications to help limit side effects. I think a big portion of managing side effects is finding the correct combination for each patient. I know lots of infusion areas offer peppermints to help with nausea. Chewing on a piece of ginger would be a little (alright VERY) odd to patients but if there was a candy or something small with the essential oils with the same effect.

What other questions does the article raise about current practice?
My questions are the same as others- should we be doing more research on on candies with these essential oils to help? Should we be doing more studies on other scents. OSU approved the use of lavender/ peppermint/ lemon but others could be just as effective.

For scalp cooling- there needs to be more research on the topic to see if it’s beneficial? Does the stage of cancer determine effectiveness (both for scalp cooling and essential oils) or just the correct regimen of anti-emetics/ etc?

Do you agree/disagree with the conclusions of the author, why?
I would love to see more done with alternatives to medicine and efficacy with managing side effects. I feel essential oils might be at an uphill battle because we are exposed to them as people trying to sell them to us.

[shawver.25]

Greg/ Kelly- I would agree that many of us are exposed to essential oils as somebody trying to sell them to us. Working in thoracic I had sooo many patients request lavender every 3 weeks because they swore by it. So for these patients I would suggest continue using essential oils if they find it helps. I don’t have any evidence to back up this claim but I feel essential oils will work if patients have a good experience whereas if patients don’t have a good experience they will be more averse to trying them again in the future.

Michelle- That is crazy the effective time range for scalp cooling being a difference of up to 1 hour prior AND 4 hours after. To me that seems like a huge range and if I were that patient I would think “ohhh I only did 30 minutes prior and 2 hours after should I have done more time to prevent the hair loss/ thinning.”

[hsu.243]

Hello everyone, I’m Stephanie from CTU ambulatory clinic.
What was the knowledge gained from the article?
I’m always interested in learning about alternative non pharmacologic therapies that could help our oncology patients manage their symptoms caused by their treatments. Thank you, Michelle, for leading this journal club.
I was aware of the use of the cooling caps to decrease chemotherapy-induced alopecia from my floating experience to the Stephanie Spielman Comprehensive Breast Center but did not know how it reduced alopecia and how to set it up for patients. After reading this journal about the scalp cooling, I was able to get a better understanding of what it all entailed for successful therapy with the greatest success. I was able to get a better understanding of how it saves hair follicles and why it may have different results for different patients, such as hair texture, having decrease results due to the insulating feature of the thicker hairs in African American individuals.
I was aware there were different essential oil options throughout the James, but never knew which essential oils was therapeutic for a particular ailment. The journal written by the Morehouse team gave me some knowledge to their uses such as, ginger EO for fatigue and anxiety. In my Asian culture ginger has always been a huge part of our meals and was utilized more for flavoring and some medicinal purposes but never thought of using it in an essential oil form for fatigue and anxiety.
What other questions does the article raise about current practice?
I would be curious to see the cooling cap study be expanded to see its effectiveness with a larger population of patients with different regimens.
I would be interested to see the effects of different essential oils combined with each other to have perhaps a complimentary effect, such as how steroids enhance the effectiveness of antiemetics.

Do you agree/disagree with the conclusions of the author, why?
I agree with both journals that there is more information and data needed to make the sample size larger and more diverse. For example, many of the cooling cap participants were female breast cancer patients. The essential oils study had many difficulties due to the pandemic and because many of the patients’ regimens were well managed having minimal side effects.

[hsu.243]

Michelle
I too, dropped the ball with the recommendations of EO. I just never felt I had enough knowledge or evidence to suggest its use in our patients. I also agree when I would see our breast cancer patients using the cooling caps, it never looks very comfortable. I always felt it would tear out the hairs from placing and removing the very tight caps.
Thank you for introducing the EO journal by the Morehouse team, congratulations to them for their publication.

Kelly
I agree that it is difficult to believe there is no further advancements in cooling cap therapy since its been around for so long. Also, agree on the potential benefits of EO in our clinical trial patients. Especially for those who are prohibited to use certain medications due to absorption of their oral therapies.

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