Gynecological Oncology Navigation by Penny Daugherty, RN, MS, OCN, ONN-CG

1. Northside Hospital Cancer Institute Gynecological Oncology Navigation …I Am Woman Penny Daugherty, RN, MS, OCN, ONN-CG Gynecologic Oncology Nurse Navigator

2. Zero Disclosures 2

3. Description and Objectives • Description: This session will define the various diagnoses classified as gynecologic malignancies and address the discreet nuances of each disease, as well as recognition and management of specific side effects associated with individual syndromes. Conventional and targeted therapies will be reviewed, as well as a discussion assisting patients in the selection of integrative approaches to care • Objectives: Upon completion of the session, participants will be able to: – Describe the significance of the various diseases that encompass the scope of gynecologic malignancies – Define the role of clinical and patient navigators through the cancer care continuum for the gynecologic oncology patient and caregivers – State the management, guidance, and care of various side effects associated with gynecologic malignancies and their therapies, as well as gain understanding of various integrative modalities 3

8. Diagnosis of Ovarian Cancer 8

9. Epithelial Ovarian Cancer Physical Symptoms • Abdominal discomfort • Feeling full after eating small amount of food; inability to eat a full meal • Bloating • Constipation • Increasing abdominal size or waistline • Pelvic discomfort • Shortness of breath • Urinary frequency/urgency Physical Exam • Ovarian mass • Abdominal swelling with fluid wave • Abdominal mass (no wave) • Decreased breath sounds at lung bases (late sign) • Firmness of umbilicus (navel) 9

10. Treatment of Ovarian Cancer Surgery • Removal of the uterus (hysterectomy), both ovaries and fallopian tubes (bilateral salpingo- oophorectomy [BSO]) AND/OR Chemotherapy • May be given through a vein or into the peritoneum (abdominal cavity) 10

11. Cervical Cancer: Anatomy of Exocervix and Endocervix • Exocervix: part of the cervix next to the vagina • Types of cells covering the cervix: – Squamous – Glandular • Endocervix: part of the cervix closest to the uterus • Transformation zone: location in the cervix where the squamous cells and glandular cells meet 11

12. Classifications of Cervical Cancer Squamous-cell • 80% to 90% of cervical cancers • Develops in the squamous cells that cover the surface of the exocervix Adenocarcinoma • Develops in the mucous-producing cells of the endocervix Adeno-squamous carcinoma • Features of both squamous-cell and adenocarcinoma Others: Melanoma, sarcoma, lymphoma (uncommon) 12

13. Cervical Cancer Signs and Symptoms • Usually shows no symptoms • Abnormal vaginal bleeding – Bleeding after intercourse – Bleeding after menopause – Bleeding between periods • Unusual discharge from vagina • Pain during intercourse 13

14. Cervical Cancer Treatment 14 Treatment depends on the stage of the cancer Surgery Radiation therapy Chemotherapy

15. • Body of uterus has 2 main layers: – Endometrium – Myometrium • Nearly all cancers of the uterus start in the endometrium 15 Endometrial Cancer: Anatomy

16. Differentiation of Uterine Cancer • Uterine carcinosarcomas ▫ Stromal carcinoma, leiomyosarcoma • Adenocarcinoma • Cervical cancer 16

17. Uterine Cancer Signs & Symptoms • Unusual vaginal bleeding, spotting, or other discharge • Pelvic pain, pain with intercourse • Weight loss • Late signs and symptoms: ascites, jaundice, bowel obstruction 17

18. Diagnosis • Any signs and symptoms must be reported to the doctor • Pelvic exam and transvaginal ultrasound • Endometrial biopsy, hysteroscopy, D&C • CA125 18

19. Treatment Main treatment: hysterectomy, BSO, lymph node dissection, omentectomy, peritoneal biopsies, tumor debulking, lymph node biopsies… Radiation therapy: brachytherapy (low-dose/high-dose), external beam radiation, may receive neoadjuvant radiation therapy Hormonal therapy: Progestins (Provera, Megace), tamoxifen, gonadotropin-releasing hormone agonists, aromatase inhibitors Chemotherapy: Usually combination “sandwich therapy” 19

20. We of the “fairer” sex are unique! (Just ask us!) • Are all about planning our day, and our lives...and the lives of those we love • Are not at all happy to have that day, that plan, or that life interrupted • Are capable of GREAT drama when confronted with ANYTHING we do not choose to do or have in our bodies

21. Initial Diagnosis The gynecologic oncology patient generally learns her diagnosis postop—or postprocedure. ONN introduction must be strong, supportive, and accepting of whatever behavior the patient and her caregivers exhibit. Assurance of a future is critical! Equally important is the promise that you will be there helping to navigate that future.

22. Key Issues – aka, Timing Is EVERYTHING! • Patient priorities revolve around survival: GLOBAL and SUDDEN LOSS of CONTROL • Understanding is golden key to navigating women through this terrifying journey • Approach is as unique as each woman • Opportunity for ONN to establish presence and supportive partnership

23. A Step-by-Step Approach (Baby Steps...) • If possible, visit with the patient in her room • Ask to sit down with her “a moment” and briefly identify your role (no standing/sitting on the bed) • Revisit the patient while in hospital to establish rapport • Make a postdischarge phone call to identify needs that surfaced upon returning home • Commit to meeting the patient at the first treatment, if possible

24. 24 • Learn as much as possible about the patient: • Where does he/she live? • How far will they travel for treatment? • Insurance? Copays? • There can be significant geographic, economic, linguistic and educational barriers to oncology care access • Distance from institution has been shown to influence many factors Background and “Baggage”

25. 25 Know your RESOURCES • Understanding and acceptance is crucial for the rural patient and family • ACS Navigator may provide lodging, gas vouchers, free wigs, travel assistance • Disparities Navigator can help with financial assistance and referrals to appropriate agencies • Social worker has access to many services • USE YOUR RESOURCES with compassion, respect for human dignity

26. The Non-English–Speaking Patient • Provision of interpreter • Maintain eye contact and SIT DOWN Know your community Know your resources Know your referral sources Know your ancillary services Know your patient – family-support system • Respect all cultural differences • ALWAYS seek that common bond

27. Education • Keep it simple (think big but start small) • Meet them "where they are" • Provide authentic bidirectional communication • Cancer is largely out of the patient’s control; focus on support and empowerment • Understand patients are often intimidated and overwhelmed when communicating with medical professionals • Include caregivers and encourage questions

28. Education (cont'd) • Assist patients in understanding: – Symptoms – Meds – interactions – Body changes – Energy-level fluctuations – Markers/test results Always solicit feedback from the patient— do not assume comprehension.

29. 29 So many treatment options

30. 30 Robotics Anyone??

31. Treatment Options Robotic Surgery

32. 32 Radiation Therapy

33. Gynecologic Radiation Treatments Daniel Lenard, R.T.(R)(T)(ARRT) Director of Oncology Services Baptist Cancer Center – Baptist Hospital, North Mississippi

34. GYN Radiation treatment options 3 4

35. Image Guided Brachytherapy 3 5

36. Intracavitary treatments 3 6

37. Intracavitary treatments 3 7

38. Interstitial Treatment 3 8

41. 41 Chemotherapy

42. 42 Chemo Modalities

43. 43 Nutrition 101

44. 44 Food Is POWER! • Empowering for patients and caregivers • Determine baseline of patient’s nutrition • Discuss benefits of well-balanced meals • Organic choices if possible • Discuss snacks – protein + carbohydrates • Small meals • Possible use of plastic forks/Pyrex cookware for metal taste in mouth • 64 ounces of clear fluid/day – HUGE – provide rationale

45. Food Factoids… Cancer Promoters: “Cons” 1. Energy-dense foods 2. Sugary drinks 3. Salty and processed foods 4. Red meats, including processed meats 5. >1-2 alcoholic drinks 6. Oils: soy/sunflower/corn/trans fats 7. Omega-6 fatty acids Cancer Blockers “Pros” 1. Nutrient-dense foods 2. Green tea/pomegranate juice 3. Herbs & spices (tumeric, garlic) 4. Fish, vegetable proteins (lentils, tofu) 5. Glass of red wine (pinot noir) 6. Oils: olive/canola 7. Omega-3 fatty acids

46. Supplements… “Loaded Topic” • Crucial to have patient provide you with list of all supplements/herbals • Evaluate supplements versus treatment: – Radiation therapy (RT) patents do NOT need to supplement with antioxidents while going through RT – Patients on blood thinners do NOT need to be on Curcumin – Patients should not take supplements on the day prior, day of, or day after chemo • When possible, supplement with REAL food

47. Quality of Life Spirituality • Most patients welcome and benefit from spiritual care during a health crisis • Spirituality and religiosity are well recognized as factors that affect patients’ quality of life and overall satisfaction: • Less anxiety • Greater well-being • Less depression Utilize and partner with chaplaincy as an integral part of the navigation process. Patient Support • ONN can facilitate access to quality psychosocial care from diagnosis through continuum • Ongoing patient-driven support group offers opportunity for education and peer-to-peer psychosocial support • Ease of access and varying times facilitates optimal participation 47

49. Role of ONN in Genetic Counseling • Assess readiness to accept information about genetic counseling during adjuvant chemo/RT • Provide preprinted FAQ sheet • Empower patients as participants in their future

50. • Maintain availability for dialogue/questions and “consequences” of testing • Educate BRCA-positive patients about PARP inhibitor trials and immunotherapy, which are based on gene mutations • Educate about drugs based on estrogen receptor– /progesterone receptor–positivity: tamoxifen/aromatase inhibitors

51. Treatment Related Sexual Dysfunction Chemotherapy • Fatigue • Nausea • Alopecia • Ovarian failure • Pain • Mucositis • Neuropathy Radiation • Vaginal stenosis • Tissue fibrosis and agglutination • Ovarian failure • Vaginal dryness • Atrophic vaginitis • Pain and bleeding with intercourse • Fatigue 51

52. 52 Surgery • Alteration in appearance/function of genital structures important to sexual function • Radical hysterectomy can shorten length of vagina • Lymphedema • Bilateral oopherectomy triggers dramatic entry into menopause: • Vaginal dryness • Lowered libido • Hot flashes/mood swings • Infertility

53. 53 Medications Altering Sexual Function • Antidepresssants – Zoloft, Paxil, Prozac may cause delayed orgasm or anorgasmia • Antiemetics • Benzodiazepines • Alcohol

54. 54 Integrating Sexual Health Assessment into ONN Practice Obtain a baseline sexual function assessment • Female Sexual Function Index (FSFI) or Female Sexual Dysfunction Questionnaire • Open-ended questions: • “Many women have talked to me about some sexual/female discomfort with treatment. Have you had any issues?”

55. • Inclusion in decision process • Honest information • To be listened to • Practical help (transportation, medicines, equipment) • Support/assistance at home • Privacy respected • Not to be anonymous What Family Members/Caregivers Want…

56. Enhancing Partnerships Helping Caregivers Build Better Relationships • For couples: Have a “no-cancer” date night • Work less • Simplify and reduce the stress at home—say “No” • Exercise together • Be patient with role changes • Don’t fight over food • Don’t take anger personally • If you are depressed, get help • Choose appropriate coping tools • TALK it out

57. Survivorship Long-term side effects of cancer treatment – Organ damage: lung, heart, kidney – Secondary cancers – Psychosocial issues: fertility, financial, PTSD • As patient nears completion of treatment, optimistically navigate them toward survivorship activities • Educate them about the survivorship activities in your facility • Introduce them to a participating survivor • Reassure them that you will be available if needed 57

58. • This is true terror for the patient, and everything you have done with their initial care will provide the basis for this very fragile time—more fragile with each recurrence • If the doctor allows, steer the dialogue toward palliative care/chronic disease scenario • ALWAYS include approved caregivers in the navigation process • Provide appropriate referrals • Work as closely as possible with the mid-levels on the team • If patient is admitted, enlist supportive hospital services: pastoral/health-psyche/nutrition/social work Recurrence!

59. • Gynecologic oncology patients are a unique specialty for a navigator • Not a big window for a survivorship interval in many cases • This is an intense/gestalt affiliation with these patients • So...go into this with eyes open and a commitment to stay the course with each patient—they deserve our BEST!

60. Questions Are Always Welcomed

61. My Contact Information: Penny Daugherty, RN, MS, OCN, ONN-CG Penny.Daugherty@northside.com Office: 404-459-1657 Cell: 676-787-6427 61

62. Appendix/Extra Information: 62

63. Oncology Patient Navigation Program • Bone Marrow Transplant and Breast Program • Formalized program began in 2010 • Oncology nurse navigators (ONNS) care across continuum • Breast • Melanoma • Gynecologic • Thoracic • Gastrointestinal/ genitourinary • Disparities Navigator • American Cancer Society Resource Navigator

64. Gynecologic Oncology Program 7 gynecologic oncologists across 3 practices • 7 radiation oncologists • Support from: • 9 nurse practitioners and 1 physician assistant • 2 hospitalist nurse practitioners • 3 clinical coordinators • 7 genetic counselors • 2 research coordinators • Case management • Biorepository

65. Ovarian Cancer • Most gynecologic cancers have precancers that may be detected before the malignant; second most common gynecologic malignancy with the highest mortality • Almost 75% of patients present with an advanced stage of disease • The risk for relapse in advanced-stage disease is as high as 70% • About 15% of women are diagnosed at a local stage before the disease has spread to lymph nodes or organs • There is no effective diagnostic test available (yet) • The incidence increases with advancing age (transformation EXCEPT most ovarian cancers) 65

66. Differential Diagnosis: Ovarian Cancer 66 Epithelial 90% of all ovarian cancers Said to occur most in women around 60 years of age Stromal (from hormone-secreting cells) Benign: granulosa cell – generally well-behaved Serolii-Leydig tumors – somewhat well-behaved Malignant: granulosa cell tumors – NOT well behaved Most often occurs in women over the age of 50 years Not as aggressive; prognosis can be good Germ-cell tumors Occur most often in young women Prognosis may be good with chemotherapy

67. Definitive Diagnosis • Careful history and physical • Pelvic ultrasound (level III/IV) • CT of chest, abdomen, pelvis • CA 125 (blood test) • Surgery by gynecologic oncologist MUST have tissue for definitive diagnosis • CT-guided biopsy • Surgical removal (resection) or portion of the tumor removed at surgery 67

68. Cervical Cancer • 13,240 estimated new cases in 2018 • 45% of cases diagnosed in a localized stage (before the cancer has spread to other areas) • 5-year survival rate estimated at 91.7% for cases diagnosed in the localized stage • 5-year survival rate estimated at 56% for cases diagnosed at a regional stage (disease has spread to areas near the cervix) • Most commonly diagnosed in women 35 to 44 years old 68

69. Cervical Cancer Risks • HPV infection • Smoking • Immunosuppression ▫ HIV/AIDS ▫ Medical immunosuppression: autoimmune disease, organ transplant • Chlamydia – bacterial infection spread by sexual contact • Diet low in fruits and vegetables • Long-term use of oral contraceptives (birth control pills) • Low income • Diethylstilbestrol (DES) • Family risk 69

70. HPV Infection Risks • Having sex at a younger age • Multiple sexual partners • Uncircumcised men HPV Infection May Lead To Cancer • Cervix • Vulva • Vagina • Penis • Anus • Mouth • Throat Symptoms • May be no visible signs 70

71. Uterine/Endometrial Cancer • 63,230 new cases estimated in 2018 • 67% of cases are diagnosed in a localized area (before spreading to lymph nodes or other organs) • 5-year survival rate for localized endometrial cancer is 91% • 5-year survival rate if diagnosed when cancer spread to regional lymph nodes is 69% • Most commonly diagnosed in women ages 45 to 74 71

72. FAQs from patients re genetic counseling: What is genetic counseling? • I already have/had ovarian cancer, why do I need genetic counseling? • What type of tests will the genetic counselor talk to me about? • What are the benefits of testing? • If I test positive, will it affect my health insurance coverage? • I know that I don’t want testing. Do I still need to have genetic testing if I am positive? • Who in my family is at risk for inheriting the genetic change that increases cancer risk? • What would I do differently if I tested positive? • I still have more questions. How do I find out more information?

73. Education Courses > Site-Specific Cancer Series: Gynecologic Cancers Web Course Books > Clinical Gynecologic Oncology DeSaia and Creasman > Atlas of Staging in Gynecological Cancer > Contemporary Issues in Women’s Cancer Suzanne Lockwood

74. 74

Gynecological Oncology Navigation by Penny Daugherty, RN, MS, OCN, ONN-CG

Gynecological Oncology Navigation by Penny Daugherty, RN, MS, OCN, ONN-CG

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