Models of education in supportive care

Conflict of Interest Disclosure Antonuzzo Andrea, MD

Has no real or apparent conflicts of interest to report.

My Agenda

•  Background

•  NICSO and education in Italy

•  Education in EU •  Education in developing countries

Background

Definition: •  Education is the process of facilitating learning, or the acquisition

of knowledge, skills, values, beliefs, and habits. •  Educational methods include storytelling, discussion, teaching, train-

ing, and directed research.

Background

Educa&on   frequently  takes   place   under   the  guidance   of   educators,  however   learners   may  also  educate  themselves  

Background – supportive care How to perform education in supportive care?

Rigorous scientific method

In Italy NICSO is the ‘’key’’ (Italian Network for Supportive Care on Oncology)

Education with NICSO LETTER TO THE EDITOR

NICSO: Network Italiano Cure di Supporto inOncologia – ItalianNetwork for Supportive Care in Oncology

Fausto Roila & Carla Ida Ripamonti & Andrea Antonuzzo &

Paolo Bossi

Received: 12 September 2014 /Accepted: 1 October 2014 /Published online: 16 October 2014# Springer-Verlag Berlin Heidelberg 2014

In the oncological setting, there is an increased need of acomprehensive personalized assessment of the patients as wellas the oncological therapy related symptoms, toxicities, and/orcomplications from diagnosis to treatment and follow-up.Patient’s needs are still growing also in terms of psychosocial,spiritual concerns, and well-being during all the trajectory ofcancer disease.Moreover, there is an increase in the number ofcancer survivors (triple over the last years) carrying severalneeds linked to the late effects of cancer and its treatments [1].Cancer treatments themselves are becoming longer, thanks tothe increased survival and opportunities given by targetedtherapies and can provoke chronic-related symptoms. Withan increasing use of oral anticancer agents, the issue ofassessing and improving adherence to therapies is crucial forthe efficacy of the treatments [2, 3].

Also in this regard, the need of supportive care therapies tobe performed in conjunction with oncologic prescriptions isbecoming evident [4–6].

We can therefore assess that the “scenario of treat-ment” is changing. So far, in 2014, the Italian Networkof Supportive Care in Oncology (NICSO—NetworkItaliano Cure di Supporto in Oncologia, http://www.

nicso.it) was born with the mission to promoteknowledge, widespread education, and performcollaborative research with the final aim of improvingsupportive care in cancer patients. The MultinationalAssociation of Supportive Care in Cancer (MASCC)certified the recognition of NICSO during the last an-nual meeting in Miami 2014. The Network does nothave political or confessional characteristics and it isnon-profit. The Network is already performing and de-veloping epidemiological studies, biomedical research aswell as educational programs to release to all profes-sional medical and nursing personnel, psychologists,social workers, volunteers, chaplains, patients, and theirassociations. Among the aims of NICSO, there is alsothe assistance and support of the growth and scientificculture of young people by support to meetings andawards, also through other collaborating institutionsand development of communication skills, particularlyfor medical-scientific congress organization, video re-leases, informative books, and brochures related to pa-tients or health professionals. NICSO promotes partici-pation in medical-scientific congresses and publicationof articles or independent reviews. At the beginning of2014, a dedicated website was created as a tool for allmembers to interact. Actually, NICSO professionals in-volved are medical oncologist, radiotherapist, nurses,and psychologist-psycotherapeutics. After the firstNICSO meeting held in Rome on May 12th, threeprospective trials implemented by the network are underethical committees evaluations. These three observation-al studies address currently clinical daily practice prob-lems such as fatigue, mucositis, and hypertension due totargeted therapies. Five working groups were composedamong the participating members according to the fol-lowing topics in the field of supportive care: 1. newtoxicities due to targeted therapies, 2. adverse events

F. RoilaMedical Oncology Unit, S Maria Hospital, Terni, Italy

C. I. RipamontiSupportive Care in Cancer Unit, Fondazione IRCCS, IstitutoNazionale dei Tumori, Milan, Italy

A. Antonuzzo (*)Supportive Care in Cancer Unit, Medical Oncology 1, PoloOncologico, Pisa, Italye-mail: andrea.antonuzzo@tin.it

P. BossiHead and Neck Medical Oncology Unit, Fondazione IRCCS, IstitutoNazionale dei Tumori, Milan, Italy

Support Care Cancer (2015) 23:11–12DOI 10.1007/s00520-014-2470-2

Aims Our Network is already performing and developing epidemiological studies, biomedical research

as well as educational programs to release to all professional medical and nursing personnel, psychologists, social workers, volunteers, chaplains, patients, and their associations.

Aims Among the aims of NICSO, there is also the assistance and support of the growth and scientific culture of young people by support to meetings and awards, also through other collaborating institutions and development of communication skills: -  medical scientific conferences organization -  informative books, and brochures related to patients or

health professionals -  video releases

NICSO promotes participation in: -  medical scientific conferences (like MASCC) -  publication of articles or independent reviews -  inscription for each new member to NICSO and MASCC

Aims

Models of education in supportive care

Italy

Education in Italy NICSO promoted meetings across Italy in 2016 and 2017

Models of education •  Meetings not only for discussing topics of supportive care (e.g. nausea

and vomiting, fatigue, IO tox, neutropenia, etc…)

•  Preparation of NICSO‘s research study dashboard directly involving partecipants (oncologists, nurses, psychologists)

•  Evaluation of proposals suggested by partecipants

•  Discussion about the better way to implement adherence to supportive care items

IL DOLORE IATROGENO IN ONCOLOGIA

Carla Ida RipamontiPaolo BossiFondazione IRCCS Istituto Nazionale dei Tumori, Milano

Books….

..and papers

REVIEW

©2016 by EDIMES - Edizioni Internazionali Srl. All rights reserved

NEW MICROBIOLOGICA, 39, 3, 174-180, 2016, ISN 1121-7138

Received June 17, 2016 Accepted June 26, 2016

INTRODUCTION

In cancer patients it is common to diagnose neutropenia (defined in the consensus guidelines of the Immunocom-promised Host Society [IHS] (Hughes 1990) as a neutro-phil count of 500 cells/mm3 or less or a count of <1,000 cells/mm3 with a predicted decrease to <500 cells/mm3), which can be correlated either to the malignant neoplasm itself or to antineoplastic chemotherapy. The Common Toxicity Criteria of Adverse Events of the National Cancer Institute (CTCAE-NCI, version 4.03) de-lineates neutropenia into four grades following the abso-lute neutrophil count (ANC):

grade 1: ANC from 1.5 to 2 x 109/L,grade 2: ANC from 1 to 1.5 x 109/L,grade 3: ANC from 0.5 to 1 x 109/L,grade 4: ANC below 0.5 x 109/L.

Neutropenia is often complicated with fever: such condi-tion is commonly known as febrile neutropenia (FN), de-fined as an oral temperature >38.5°C or two consecutive readings of >38.0°C for 2 h and an absolute neutrophil count <0.5 x 109/L, or expected to fall below 0.5 x 109/L.Medical oncologists’ attention is mainly focused on che-motherapy-induced neutropenia and FN. Chemothera-

py-induced neutropenia (CIN) and chemotherapy-induced febrile neutropenia (CIFN) are conditions of neutropenia and FN respectively, whose primary cause is the admin-istration of anti-cancer drugs (the time of onset of neu-tropenia and FN is the main factor that can be used to value such connection). They are the most serious haema-tological toxicities of cancer chemotherapy and they stand among the main mortality causes in cancer patients.Neutropenia and FN are common in cancer patients because of several risk factors that can be either due to the patient’s characteristics, to the disease itself or to the treatments.Table 1 shows the principal risk factors associated with the development of FN (adapted from Danova 2015).Considering the different chemotherapy regimens, cer-tain therapy regimens are associated with a high risk of neutropenia and FN (i.e., a ≥20% risk of developing FN). These include schemes used in several malignancies, re-ported in Table 2.Other drugs used in cancer treatment are associated with high risk of neutropenia and FN because of their mecha-nism of action. These include:

bortezomib, used in the treatment of multiple myelo-ma, that inhibits the proteasome, permitting the acti-vation of programmed cell death in neoplastic cells, but also in myeloid normal cells;alemtuzumab, monoclonal antibody anti-CD52, used against B-cell chronic lymphatic leukemia, which acts against both malignant and normal B and T lymphocytes;rituximab, monoclonal antibody anti-CD20, used in the treatment of several non-Hodgkin lymphomas;corticosteroids, because of their immunosuppressive effects.

SUMMARY

The use of procalcitonin (PCT) as an early marker of infectious episodes in cancer patients is still contro-versial. We performed a MEDLINE search of peer-reviewed articles published between January 1990 and December 2015, and finally we analysed 15 articles. PCT seems to have a good diagnostic value of infectious episodes in cancer patients and its accuracy seems greater if we consider major events, such as bloodstream infections and sepsis. Serial evaluations of this protein seem to be more accurate in the diagnostic phase and useful to predict outcome and response to antibacterial treatment. On the other hand, some issues have yet to be solved, such as the use of a validat-ed method of determination, the definition of a standard cut-off, and the heterogeneity among different settings of patients (e.g. early versus advanced-stage cancer, or haematological versus solid tumours).However, it is credible to think that PCT use in everyday clinical practice, preferably in combination with other clinical or laboratory tests, might be of help in finding and detecting early infectious complications in cancer patients.

Key words:Cancer patients, Procalcitonin, Infections, Chemotherapy-induced neutropenia, Febrile neutropenia, Biomarkers of infection.

Corresponding author:Andrea Sbrana, MDE-mail: andreasbrana89@gmail.com

Use of procalcitonin in clinical oncology: a literature reviewAndrea Sbrana1, Martina Torchio2, Giuditta Comolli3, Andrea Antonuzzo1, Marco Danova2,on behalf of the Italian Network for Supportive Care in Oncology (NICSO)1Polo Oncologico, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; 2Medicina Interna e Oncologia, Ospedale Civile di Vigevano, ASST Pavia, Italy; 3Laboratori di Ricerca Biotecnologie e S.C. Microbiologia e Virologia, Fondazione IRCSS Policlinico San Matteo, Pavia, Italy

ORIGINAL ARTICLE

Prevalence, characteristics, and treatment of fatigue in oncologicalcancer patients in Italy: a cross-sectional study of the Italian Networkfor Supportive Care in Cancer (NICSO)

Fausto Roila1 & Guglielmo Fumi1 & Benedetta Ruggeri2 & Andrea Antonuzzo3 & Carla Ripamonti4 & Sonia Fatigoni1 &

Luigi Cavanna5 & Stefania Gori6 & Alessandra Fabi7 & Nicola Marzano8 & Claudio Graiff9 & Vitaliana De Sanctis10 &

Aurora Mirabile11 & Samantha Serpentini12 & Chiara Bocci13 & Maria Simona Pino14 & Giuseppina Cilenti15 &

Claudio Verusio16 & Enzo Ballatori17 & on behalf of NICSO (Network Italiano per le Cure di Supporto in Oncologia)

Received: 6 March 2018 /Accepted: 31 July 2018 /Published online: 6 August 2018# Springer-Verlag GmbH Germany, part of Springer Nature 2018

AbstractBackground Fatigue is one of the most distressing symptoms of cancer patients. Its characteristics and impact on quality of lifehave not been fully explored and treatment of cancer-related fatigue in Italian oncological centers has not been codified.Methods A cross-sectional study was carried out on all patients attending for any reason the 24 participating centers in two non-consecutive days. Patients with fatigue filled out the Brief Fatigue Inventory (BFI) questionnaire and reported any pharmaco-logical or non-pharmacological treatment for fatigue.Results From October 2014 to May 2015, 1394 cancer patients agreed to participate in the study. Fatigue was referred by 866(62.1%) of patients; its duration was > 4 months in 441 patients (50.9%). In the investigators’ opinion, the most important (probableor almost sure) determinants of fatigue were reduced physical activity (271 patients), anxiety (149), pain (131), insomnia (125),anemia (123), and depression (123). Fatigue of moderate/severe intensity was reported by 43%/29.2% of patients, while usualfatigue in the last 24 h by 45%/33.1%, and the worst fatigue in the last 24 h by 33%/54.8%, respectively. Concerning the impact onquality of life, fatigue interfered moderately/severely with general activity in 30.8%/38.6% of patients, with mood in 26.1%/32.8%,with the ability to work in 27.9%/35.6%, with normal work in 26.7%/38.9%, with relationships with others in 21%/23.4% and withthe ability to amuse themselves in 22.2%/33.1%. Only 117/866 patients (13.5%) received a pharmacological treatment representedby a corticosteroid in 101 patients (86.3%) while 188 patients (21.7%) received a non-pharmacological treatment such as physicalexercise (120 patients, 63.8%) and various alimentary supplements (52 patients, 27.6%).Conclusions Cancer-related fatigue is frequently reported by oncological patients; its intensity and impact on quality of life is relevant.

Keywords Cancer-related fatigue . Characteristics of fatigue . Pharmacological treatment . Non-pharmacological treatment

* Fausto Roilaroila.fausto@libero.it

1 Azienda Ospedaliera S. Maria S.C. Oncologia, Terni, Italy2 Clinical Governance, ASUR Marche, AV5, Ascoli Piceno, Italy3 University Hospital of Pisa, Pisa, Italy4 Oncology Unit 2, Istituto Nazionale dei Tumori, Milan, Italy5 Oncologia-Ematologia-AUSL PIACENZA, Piacenza, Italy6 Oncology Unit, Ospedale Sacro Cuore Don Calabria,

Negrar, Verona, Italy7 Division of Medical Oncology, BRegina Elena^ National Cancer

Institute, Rome, Italy8 UOSD Oncologia Medica Ospedale S. Paolo, ASL, Bari, Italy

Supportive Care in Cancer (2019) 27:1041–1047https://doi.org/10.1007/s00520-018-4393-9

9 Ospedale Centrale di Bolzano, Bolzano, Italy

10 Radiotherapy, St. Andrea Hospital, Sapienza University, Rome, Italy

11 Azienda Ospedaliera S.Antonio, Gallarate, Italy

12 Istituto Oncologico Veneto IOV-IRCCS, Padua, Italy

13 Fondazione Salvatore Maugeri, I.R.C.C.S., Pavia, Italy

14 SOC Oncologia Medica Ospedale S. Maria Annunziata,Florence, Italy

15 Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo,Foggia, Italy

16 ASST della Valle Olona, Hospital of Saronno, Saronno, Italy

17 Spinetoli, Ascoli Piceno, Italy

The key role of multisciplinarity •  Wide angle in Supportive Care

–  Multiprofessional and interdisciplinary national meeting every year in Bologna

–  Sessions with different healthcare professionals –  All about news in supportive care of the previous year

Multisciplinarity and shared education: first step Involvment  of  Italian  Medical  Oncology  community  

Multisciplinarity and shared education: second step

responsabili scientificiAndrea AntonuzzoPaolo BossiCarla Ida RipamontiFausto Roila

CONVEGNO » 10.5 CREDITI FORMATIVI

FOCUS SU TERAPIE DI SUPPORTO 2018

Bologna, 7-8 maggio 2018

SEZIONE DI ONCOLOGIA

Involvment  of  European  associa8on    for  Suppor8ve  Care  

responsabili scientificiAndrea AntonuzzoPaolo BossiCarla Ida RipamontiFausto Roila

CONVEGNO » 9.8 CREDITI FORMATIVI

FOCUS SU TERAPIE DI SUPPORTO 2019

Bologna, 13-14 maggio 2019

SEZIONE DI ONCOLOGIA

SALA STROMBOLI – 20 Nov La collaborazione tra i MMG e la rete dei PS-DEA Silvestro Scotti 09.00 – 09.20 SIMEU collabora con MMG Gaetano Piccinocchi 09.20 – 09.40 Il paziente oncologico in PS Gianmauro Numico

Cooperation with other Italian scientific society

Scien&fic  Society  of  Emergency  Medicine    

Education for General Practitioner •  Young Medical Doctor involved in post-graduate training

•  Lessons together with local opinion leader in supportive care in oncology

•  Annual meeting with regional association of General Practitioners

Models of education in supportive care

EU

Education in EU •  NICSO warrants research through these working groups and tries to

create further collaborations with other European supportive care associations like the French and German associations.

•  Proposal of phase IV research study after literature review paper publication

•  Idea and proposal to share some contents of the three different national websites (“same language”)

Education with MASCC affiliated national groups •  Implementation of national groups and associations within the

umbrella of an international association of supportive care in cancer like MASCC could increase the spread of this topic in cancer treatment and could raise the number of clinical trials performed in this field.

Models of education in supportive care

Developing countries

Developing countries

•  Web ina r ( an i n te rac t i ve sem ina r conduc ted ove r the World Wide Web)

•  Free of charge online training opportunities •  Promotion of merit awards for young investigators and possibility to

fellow international hospitals with excellence in supportive care

•  To empower participation to research studies with other countries (with the help of MASCC)

To  promote:  

Developing countries

-  Undergraduate supportive care curriculum -  Supportive care rotations for oncologists/fellows

-  Conferences on supportive care for oncology professionals -  Formal testing of supportive care skills in examinations

To  promote:  

Models of education in supportive care

On the Moon, Mars…

I apologize, no answers…(at the moment…)

Conclusions

•  Activities and researches are an attempt to widespread the usefulness of supportive care across different oncological settings during this era of global crisis creating the basis for models of care “not money maker but money saver”.

Conclusions Remember always that:

More education

More knowledge

Better outcome!!!

“Learning never exhausts the mind.”  

“l’apprentissage n’épuise Jamais l’esprit.”  

“El aprendizaje nunca agota la mente.”  

“Imparare non stanca mai la mente.”  

“Lernen erschöpft den Geist nie.”  

Conclusions Remember  always  that:  

Leonardo da Vinci, 1452-1519  

Thank you for your attention!