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Online Resources

OncoTalk:  Improving Oncologists' Communications Skills
A multimedia resource from the University of Washington. "The way you communicate is part of your work as a healer.  You weren't born with communication skills-you learn them,"  Anthony Back, MD.
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Opioid REMS Update
In the April 2010 issue we discussed opioid Risk Evaluation and Mitigation Strategies (REMS).  The latest edition of the PainEDU newsletter has a summary of REMS history and current directions.  A new industry-sponsored website, Ready for REMS, also explains the history, process, and issues.
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Continuing Education


Schwartz Rounds
Schwartz Rounds will resume on September 16 at noon in a new location:  the new Smilow Cancer Hospital at Yale-New Haven in the Park Street Auditorium (CME)
  • September 16
    A Disconnect Between the Family and Medical Team

  • October 14
    What to do with a Hard-Charging Husband in Patient Care

Yale Bioethics Center End of Life Issues Group
Theme for 2010-2011:  "Ethical Aspects of the Advances in Modern Medicine." (CME)  Tuesdays 5:30pm - 7:00pm.
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  • September 14
    A Mother Should Never be Asked to Pull the Plug: Aversive Choices in Modern Medicine.  Kristina Orfali, PhD.  Child Study Center's Cohen Auditorium, 230 South Frontage Road.

  • October 5
    Child Mental Health-Centered Cancer Care Across the Lifespan.  Andres Martin, MD,MPH. 77 Prospect St, Room A002.

September 25
9th Annual Oncology Nursing Symposium
Challenges in Oncology Nursing Practice.  Smilow Cancer Hospital.  Contact: Lisa Barbarotta, MSN. (CNE)

November 15
Yale Symposium on Palliative and End-of-Life Care.  (CME)
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September 25
Enhancing Comfort in Pediatric Palliative Care
8:30am - 1:00pm.  Fairfield University. Contact: Cathy Tuttle
Registration deadline: Sepember 15.

October 8 & 15
ONS Chemotherapy & Biotherapy Course
Hospital of St. Raphael, New Haven.  Contact: Susan Fisher at (203) 789-3391.  Deadline:  September 16. (CNE)

September 17-19
First Annual Navigation & Survivorship Conference
Academy of Oncology Nurse Navigators.  Baltimore. (CNE)
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October 8 - 10
Practical Aspects of Palliative Care:  Integrating Palliative Care into Clinical Practice
HMS Center for Palliative Care.  Cambridge, MA. (CME)
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November 5 - 6
Quality of life for the Children
4th Annual Pediatric Palliative Care Conference. Washington, DC.
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November 5 - 7
Cancer Survivorship for Clinicians:  Helping Survivors Live Well Beyond Cancer

Dana-Farber Cancer Institute.  Boston. CME, CNE, SWCE, Psych CE.
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September  2010          Volume 4 No 8
Survivorship Themes: Fatigue

As we continue to review the common themes seen in survivors at the Connecticut Challenge Survivorship Clinic at Yale Cancer Center, this issue will review the second most common theme (and perhaps the most common symptom), fatigue.  As with other themes, it is reported in varying ways: 
  • Will I ever have energy again?
  • I'm so tired that I can't think straight.
  • I feel like an old lady.
  • Preparing a meal is exhausting.
  • Where will I get the energy to exercise?  I have to take a nap after I shower!
Our specialists address this concern in a hypothetical participant:

APRN: A very common physical response to insult (infection, injury, surgery, chemotherapy, radiation therapy, etc.) is fatigue.  Although it is known that certain cytokines may be involved in development of fatigue, we do not have a clear medical picture of the sometimes profound or prolonged fatigue that may be experienced by people recovering from cancer and its treatment.  It is a very frustrating symptom that may contribute to or be exacerbated by depression, anxiety, and cognitive changes.  The only known intervention for cancer-related fatigue is regular exercise.  Good nutrition, changes in routine to optimize energy use, and adoption of coping mechanisms may also contribute to successfully addressing this symptom.  As with other aspects of recovery, we cannot predict the course of fatigue for any one person.  For some it may be short-lived or of marginal concern, for others it may have a serious or prolonged impact.  Enlisting the help of family, friends, or professionals (yoga instructor, personal trainer, therapist) may be beneficial in a new lifestyle that accommodates and transcends fatigue.

Physical Therapist: During and following surgery, radiation therapy, and chemotherapy, your body may feel fatigued as it is healing from these treatments, and thus you may not feel like exercising.  A vicious circle can be created:  you feel tired, so you don't exercise, and then you become more fatigued because you have not been able to increase your energy level by exercising, and so on.  "The journey of 1,000 miles begins with a single step."  Begin slowly and keep things in perspective.  Aim for 30 minutes a day, 5 times a week as your long-term goal.  If this is too much to start with, begin with 15 minutes, 3 times a week (a day on, a day off for rest) and increase each session gradually to 30 minutes.  Then you can add in another day, (starting at 15 minutes and working up to 30).  Set a specific goal.  For example: 'I want to be able to do a 3 mile walk for breast cancer by May.'  Write your routine and goals for the week on the calendar.  Having concrete, but realistic and adjustable, plans and goals is a good strategy to keep you motivated.

Social Worker: First of all, please know most cancer survivors feel your concern.  Many medical professionals want to reassure cancer survivors and tend to underestimate the amount of time it takes to return to a previous level of energy.  I believe this is so because the doctors (and other medical professionals) hope that their patients will have an optimistic attitude, and the optimism will assist in recovery.  My suggestion is to trust your body and attune to what you can do.  In yoga, it is called "the edge," meaning go to the edge of what you can do, without pushing so hard that you go over (the edge).  The key is self acceptance and patience; it is important to trust your body and allow the necessary healing to take place as you return to "normal" functioning.

Nutritionist: "I am too tired to food shop, cook, even at times to eat." As explained above with exercise, the same vicious circle can be created:  you feel tired so you skip meals, then you become more fatigued because you are not giving your body enough fuel and nutrients. Eating 5-6 smaller meals throughout the day helps to sustain your blood glucose levels, which makes you feel more energized.   It is important to have a source of protein at every meal (cheese, skim milk, nuts, peanut butter, eggs, fish, or lean meat).  Also have two types of high fiber foods at every meal (whole grain breads, crackers, cereals, any fruit, or any vegetable).  This combination of protein and fiber helps raise and sustain your blood glucose levels, which gives your body a steady source of fuel. Even if your appetite is low, it is better to have a few bites of each of the protein and high fiber foods then trying to eat all of only one food item.   

Be careful to avoid falling into the trap of eating sweets for quick energy.  This in fact creates more fatigue and sets you up to crave more sugar and another vicious circle of fatigue continues.  Be willing to ask for and accept help from your family, neighbors, and friends with food shopping and meal preparation. Take advantage of home delivery services offered by supermarkets. Having healthy food stocked and readily available in your home and work environment will make eating well throughout the day easier.   

In the News

September is Pain Awareness Month
American Pain Foundation
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Pain Balance
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Cancer Survivorship Events
  • The Connecticut Challenge bicycle ride to raise money for survivorship programs throughout Connecticut was held on July 24th in Fairfield.  There is still time to donate in the name of a specific team or individual.  The Challenge helps to support the adult and pediatric survivorship clinics at Yale Cancer Center.
    Learn More >>

  • A special benefit concert by Band Together CT, featuring rock legend John Oates, will be held on December 1st at the Fairfield Theatre Company.  Proceeds will support the new Connecticut Challenge Survivorship Center in Fairfield.
    Learn More >>

  • The Valley-Shore YMCA in Westbrook is offering a free individualized exercise program for cancer survivors, Hope is Power (HIP), starting on September 28th.  A benefit bike tour and walk to benefit HIP and the Lance Armstrong Foundation will be held on Saturday, October 2.  Contact:  Stacy McGee, 860-399-9622
    Learn More >>

National Take-Back Day
On September 25, 2010, the Drug Enforcement Administration (DEA) will coordinate a collaborative effort with state and local law enforcement agencies to remove potentially dangerous controlled substances from our nation's medicine cabinets. Collection activities will take place from 10:00 AM through 2:00 PM  at sites established throughout the country.  The National Take-Back Day provides an opportunity for the public to surrender expired, unwanted, or unused pharmaceutical controlled substances and other medications for destruction.  These drugs are a potential source of supply for illegal use and an unacceptable risk to public health and safety.
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Journal Watch

Pain in Elders: Three recent special issues address this population:
  • Pain Management Nursing, 2010;11(2 Supp 1).
  • Surgical Oncology, 2010;19(3).
  • Oncology Nursing Forum, 2010;37(5 Supp).

Campbell ML.  When Will "Usual Care" in Advanced Illness Be "Palliative Care"?  Journal of Palliative Medicine.  2010;13(8):934-935.

Coyne P, Lyckholm L.  Artificial nutrition for cognitively impaired individuals:  Strategies to promote appropriate care.  Journal of Hospice and Palliative Nursing.  2010;12(4):263-267.

Davis MP, Walsh D.  Mechanisms of fatigue.  Journal of Supportive Oncology.  2010;8(4):164-174. (Free full text)
  • Related commentary:  Bruera E.  Cancer-related fatigue:  A multidimensional syndrome. pp 175-176.

  • Related commentary:  Ng A. The underrecognized role of impaired muscle function in cancer-related fatigue.  pp 177-178.

Ettinger DS, et al.  Non-small cell lung cancer.  J Natl Compr Canc Netw. 2010 Jul;8(7):740-801.  (This is the 2010 NCCN NSCLC clinical guideline)

Grunfeld E, et al.  Population-based longitudinal study of follow-up care for breast cancer survivors.  Journal of Oncology Practice. 2010;6(4):174-181.

Manitta VJ, et al.  Palliative Care and the Hemato-Oncological Patient: Can We Live Together? A Review of the Literature.  Journal of Palliative Medicine. 2010;13(8):1021-1025.

McCullough L, et al.  Breastfeeding in survivors of Hodgkin lymphoma treated with chest radiotherapy.  Cancer. 2010 Jul 13.

Mercadante S, Et al.  Sexual issues in early and late stage cancer.  Supportive Care and Cancer.  2010;18(6):659-65.

Nevidjon B, Chaudhary R.  Controlling Emesis:  Evolving Challenges, Novel Strategies.  Journal of Supportive Oncology.  2010;8(4 Supp2):1-10.

Redig AJ, Munshi HG.  Metabolic Syndrome After Hormone-Modifying Therapy: Risks Associated With Antineoplastic Therapy.  Oncology.  2010;24(9):839-847. (Free full text)
  • Related commentary: Van Londen GJ.  Metabolic Effects of Hormone Deprivation Therapy: Weighing the Evidence.

  • Related commentary:  Ligibel JA.  Considering Metabolic Effects When Making Breast Cancer Treatment Decisions.

Ridner SH, et al.  Breast cancer treatment-related lymphedema self-care: Education, practices, symptoms, and quality of life.  Supportive Care in Cancer. 2010 Apr 15.

Bell CJ, et al. 
End-of-life experiences in adolescents dying with cancer.  Support Care Cancer. 2010;18(7):827-35.