Evidence-based radiation side effect management

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Published: 8 May 2019
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John Hillson - Duke Cancer Institute, Durham, USA

John Hillson speaks to ecancer at ONS 2019 about evidence-based radiation side effect management.

He speaks about applying the best research available on how patients can manage their own long-term symptoms, as well as accessibility of effective cancer care.

John explains that he would like to see more research on solutions for barriers to care caused by financial toxicity, structural vulnerability and disparity of access - and that nurses are ideally placed to provide this.

Radiation oncology is a very high-tech environment and I feel that it’s an important role for the nurse to go and bring the humanity back into the high tech. There have been some very unfortunate papers written recently about how race and education, poverty, basic care and in particular the pervasive crisis in disparities of access in radiation therapy. They’ve explored statistics using SEER data with African-Americans, Hispanic Americans, American Indians. Appalachia, very close to where we practice where we’re seeing patients having worse outcomes and barriers to treatment, barriers to good screening methods and overall effective care and effective cancer care. Part of the barriers being that radiation oncology goes and uses multimillion dollar machines that we do not have on every street corner. So, for example, we’re seeing a lot of benefits with proton therapy now; we have 26 for the entire US. We’re going and building more but that does mean that it’s not available to everyone.

The bulk of the talk, though, was on taking the best research we have on how do patients go and manage their symptoms. They are usually treated as an outpatient, they’re going and living with their symptoms a lot longer than they are in front of me, and they’re taking home and they’re doing the bulk of the heavy lifting on keeping their symptoms under control and keeping as healthy as possible. Unfortunately, with a lot of the research there are no magic bullets, there are no magic potions, no shortcuts and it comes down to daily basic care. Expenses, of course, can also be a huge barrier for a number of patients. We’re finding that the basic mouthwashes, a teaspoon of salt and a teaspoon of baking soda in a cup of water, that outperforms many medications that are out there right now. Basic skincare products have proven to be every bit as effective as some of the very expensive ones.

What were some of the latest evidence-based side effect management methods that you spoke about in the session?

A number of the protocols that we have, at the end of the protocol whenever we’re running into trouble it always says, ‘Consult the experts.’ So for skin care there was a very recent paper that came out by The Journal of Dermatology and they had some very solid recommendations for skin care management. There was the Association of American Ophthalmology, I think I’m getting the acronyms wrong and apologise to them for that, but great recommendations for eye care for patients that are getting radiation therapy to the face. A lot of it comes down to moisturise and lubricate and treat infections as they come.

What developments in this area do you expect in the near future?

There has been a lot of effort to try to go and come up with some new system, some new way of doing general care, some new potion that’s going to go and take away the side effects. The best results we’ve had have been with more conformal treatments with radiation oncologists avoiding causing damage in the first place. There have been some very exciting drugs come out in the last couple of years and we’re looking at GC4419, Duke’s BMX. We’re seeing medications that are both radioprotectors and radiosensitisers, medications that can hopefully go and spare the patients a lot of side effects.

What is your take home message for oncology nurses?

There has been a lot of confusing information out there and I tried to go and provide the best data that I could as to where we genuinely have support for some of the interventions that are available. Really it came down to basics, even in this very intimidating high-tech environment it still comes down to just be a nurse and remember your training, remember to put the patient first.

What are the challenges in this area, particularly in relation to specific patient populations?

A lot of the challenges that are out there to different patient populations, I was bringing out the data not so much that we have evidence-based solutions so much as the evidence is pointing at some very large challenges that we don’t have solutions for. Really one of the things that was striking for me is when we’re looking at financial toxicity, structural vulnerability, disparities in access. While this is very much part of the nursing system a lot of the research has been done on the medical side and not a lot of nursing research that I was coming across to even go and address these issues, though it’s certainly something that very much should be coming from nursing and something that nursing should be very much involved in.

Why are nurses so important to this?

We have always been about the patient first and right from the beginning, rather than certain procedures and certain medications, it’s always been about how do we keep the patient at the centre of this. When we’re not going and addressing some of the issues like the disparities of access really then we’re going and putting technology ahead of the actual human being.