The Treatment Should Not Be Worse Than the Disease

Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Editor-in-Chief OncLive Nursing

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing Louisiana State Health Sciences Center in New Orleans, Louisiana

I recently overheard a conversation in the grocery checkout line that made me wonder how well we manage the side effects of cancer treatment. When the woman ahead of me in line told the cashier that she was sorry to hear that her father had died, the cashier responded by saying that “the cancer didn’t kill him, the treatment did.”

Whether this was perception or reality doesn’t matter. What matters is that the cashier is not alone in believing the old adage that the treatment may be worse than the disease. It’s commonplace to hear newly diagnosed patients and their families talk about relatives, neighbors, and friends who underwent cancer treatment and experienced debilitating, and sometimes lethal, side effects. I imagine that I’m not alone in responding that every person undergoing cancer treatment is unique and that one person’s experiences (good or bad) cannot predict how another person will fare. However, at the same time, I wonder about patients who experience troublesome side effects and how well, or how inadequately, those symptoms have been assessed and managed.

Patient assessment is a critical component of effective side-effect management. We need to know when a side effect began to occur, its intensity and duration, how it’s been managed, and whether it’s been managed effectively, partially, or ineffectively. Asking patients the question, “Any problems?” is not patient assessment. Patient assessment needs to include interview questions and a physical examination. Time and time again, I’ve observed nurses who took the time to review a list of possible side effects, and this review prompted patients to recall symptoms that they might not otherwise have mentioned (eg, “Now that I think about it, I do have a place in my mouth that has been sore.”). However, I’ve also seen nurses who record the patient’s responses to questions about side effects and stop there. In other words, a nurse will document a patient’s sore mouth, but not examine the mouth. When I asked a nurse about this once, she said that it didn’t matter if there was an observable sore in the patient’s mouth or not; it was sufficient that the patient had reported a sore mouth. It’s not sufficient; we need to take the next step and examine the patient. Managing the sore mouth of a patient who has lost weight and now has ill-fitting dentures is very different from managing diffuse stomatitis caused by chemotherapy or radiotherapy.

Without a full understanding of what we’re treating, chances are that the patient will be inadequately and, possibly, inappropriately treated. Side effects that are mismanaged can cause patients to delay or drop out of treatment altogether. When patients say that they discontinued cancer treatment because they couldn’t handle the side effects, aren’t they really saying that their healthcare providers fell down on their jobs and failed to effectively manage those side effects?

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When patients say that they discontinued cancer treatment because they couldn’t handle the side effects, aren’t they really saying that their healthcare providers fell down on their jobs and failed to effectively manage those side effects?”

Nurses sometimes think that side-effect management lies in the realm of medical or advanced nursing practice. However, drug information sheets and patient education materials typically instruct patients to report side effects to their doctors, nurses, and/or pharmacists. It’s our job—and duty— to appropriately and effectively manage those side effects. As patient-care providers, we need to be knowledgeable about current, evidence-based sideeffect management. At a minimum, we need to know what resources are available and how to access them (eg, National Comprehensive Cancer Network Guidelines, available at www.nccn.org; Oncology Nursing Society Clinical Practice Resources, available at www.ons.org/ClinicalResources; and Multinational Association of Supportive Care in Cancer Guidelines and Tools, available at www.mascc.org).

While some side effects require pharmacologic intervention, there are many that do not, and there are some that require both pharmacologic and nonpharmacologic approaches. Nurses have the opportunity to support patients and promote their comfort as they undergo cancer treatment; however, in order to achieve optimal outcomes for our patients, we need to have top-notch patient-assessment and side-effect management skills.