Join HSANZ
Tracy King and Jacqui Jagger have done it again - produced an excellent informative and interesting newsletter for the Nurses Group.
It includes:
A big thank you from HSANZ to those to attended Blood 2024 in Brisbane. It was a great success, with many saying that this was a very friendly and collaborative conference.
One of the most important, rewarding and positive aspects of the Society is the support we provide for our members.
A very big congratulations to this year's recipients of our Nurses awards.
Best Oral Presentation: Ty Simpson
Best First-Time Oral Presenter: Emily Minopoulos
Best Poster: Robyn Western
HSANZ Nurses Travel Grants
Photo: Emily Minopoulos - Best First-Time Oral Presenter
SRN Level 7 - $150,046 pa pro rata
Permanent Part-Time
Closing Date: 4pm 28 October 2024
Highly capable and values-driven Nurse Practitioner to join our dynamic Haematology, Cancer, Imaging and Clinical Service (CICS) team working at Sir Charles Gairdner Hospital (SCGH). You will be a driven and innovative individual whose actions, interactions and partnerships achieve high quality patient care. You will have the opportunity to embody the NMHS Values and make a real difference by providing safe quality care through expertise and teamwork.
Current and former Nurses presidents, Nicole Gavin and Elise Button recently published an article on values and preferences of haematology patients near the end of life. Much of the data came from the HSANZ membership (via the mailing list and at conference - see methods section of publication).
Click here for the publication
Are you an internationally educated nurse working in cancer or palliative care setting in Australia?
Have you obtained your initial nursing qualification overseas before migrating to Australia?
We are seeking for volunteers to participate in our study.
What is this study about?
This research aims to understand the experiences of internationally educated nurses (IEN) in the context of cancer and end-of-life care. This study explores and analyses how cultural beliefs and practices of IENs inform their delivery of nursing care. Considering the cultural diversity of Australia and its nursing workforce, understanding this phenomenon deserves attention to advance culturally sensitive care and enhance IENs' workplace experience.
Why participate?
You will contribute valuable information to advance knowledge and understanding of your experience and may inform future strategies to enhance your work experience.
Who can participate?
What do I need to do?
If you are interested in participating or would like more information, please contact Jay Balante at jay.balante@sydney.edu.au or through mobile at 0410 808 159. If you know someone who might be interested in participating, please share the study information with them.
For more information click here
This study has been approved by the Sydney Local Health District Human Research Ethics Committee – Concord Repatriation General Hospital (Protocol Number: 2020/ETH02502).
HSANZ has endorsed these Guidelines and provide them for your information. Nicole Gavin, HSANZ Associate Nurse Member was one of the authors.
CNSA would like to extend a heartfelt thanks to our Vascular Access Device & Infusion Therapy Specialist Practice Network (VAD&IT SPN), eviQ and all who have worked tirelessly to develop the revised CNSA Vascular Access Devices: Evidence Based Clinical Practice Guidelines. In a CNSA first, these guidelines are hosted directly on the CNSA website and detail the latest evidence and recommendations for patients with cancer with peripheral intravenous cannulas and central venous access devices.
The guidelines provide standardised, evidence-based clinical practice guidelines and recommendations for the safe, effective, and efficient management of vascular access devices for the patient with cancer. This knowledge base, with clinical expertise, the preferences of the individual patient, product knowledge and application, and local context of the individual healthcare environment can be integrated into comprehensive approach to vascular access management for the individual cancer patient.
They have been received enthusiastically within Australia, with endorsement coming from the Australia Vascular Access Society (AVAS), the Alliance for Vascular Access Teaching and Research (AVATAR), the Clinical Oncology Society of Australia (COSA) Intravenous Nursing New Zealand (IVNNZ) and Haematology Society of Australia and New Zealand (HSANZ).
These guidelines cover Patency, Occlusion Prevention and Management and include:
You can now access these online at www.cnsa.org.au/VADguidelines. or
The HSANZ Nurses Group Myeloma Specialist Practice Network is a very active group, with Tracy King at the helm. She not only applied for and received funding from a pharma company, however, also received an Innovation Award for developing MyeTxScheduler, a tool for clinicians to create treatment schedules to help patients to adhere to treatment protocols. The tool is pre-populated with standard myeloma treatment scheduled based on eviQ protocols, with flexibility to adapt to individual patient needs.
It is being rolled out in stages across Australia and New Zealand.
More details here
President: Nicole Gavin (QLD)
Nicole Gavin is Senior Research Fellow at Queensland University of Technology and Nurse Research at the Royal Brisbane and Women’s Hospital with adjunct affiliations at the University of Queensland and Griffith University. She is an experienced haematology and bone marrow transplant nurse. Nicole’s PhD investigated the effect of parenteral nutrition on microbial growth and its influence on catheter-related infection in patients with a central venous access device. Her postdoctoral research is broadly focused in preventing and managing infections in patients diagnosed with cancer. Nicole has been an associate nurse member of HSANZ since 2010 and has been the Queensland Representative and Vice President.
Vice President – and WA rep: Andrew Steele
Andy started working in Oncology upon qualification in 1991. His first role in Haematology was 3 years later at Derriford Hospital Plymouth and he became Charge nurse there in 1998, attending the EBMT conference the same year.
In 2000 Andy moved to Kalgoorlie WA, working in Restorative and Palliative care as a manager and stayed there for 2 years before moving to Perth to work on the Haematology ward. He stayed there for 14 years night and day and then moved to the Haematology Day Ward as Clinical Nurse Specialist and then Manager in 2014. He has been a Nurses Representative for WA since 2015. He has an interest in Change theory presenting several times at the Blood conference and organised and chaired the nurses stream of Blood 2019 in Perth.
Treasurer – Elise Button
Elise Button is a Research Fellow in the Centre for Healthcare Transformation, Queensland University of Technology and Nurse Researcher in Cancer Care Services at the Royal Brisbane and Women’s Hospital. She is an experienced haematology and bone marrow transplant nurse and an early career researcher. Elise’s research interests are focused on integration of palliative care, quality measures of end-of-life care and value-based health care.
Qld State Representative Jodie Marsh
Jodie is a Nurse Practitioner Townsville University Hospital. She has 23 years’ experience in Cancer Nursing with the majority involved in Haematology, Blood and Marrow Transplant and apheresis. She is an active member of both Haematology and BMT reference group committees with EVIQ and State Wide Cancer Clinical Network Specialist Education Committee. Clinical areas of interest are Clinical Morphology, Acute Leukemias, Apheresis and Blood and Marrow Transplant. Qld Pathology credentialled in procedural Bone Marrow Biopsy.
Myeloma Specialist Practice Network - Tracy King RN MN
Tracy King is a past President of the Nurses Group and currently, Myeloma Clinical Nurse Consultant at Royal Prince Alfred Hospital; Clinical Research Fellow, Lecturer and PhD candidate at the Cancer Nursing Research Unit, Sydney University. With over 28 years’ experience in the field of Haematology / BMT, Tracy developed a specialist interest in myeloma 20yrs ago working with the International Myeloma Foundation (IMF), now Myeloma UK. Since coming to Australia Tracy has been an active member of a range of national and international professional working groups including those of the Cancer Institute NSW; Myeloma and Related Disease Registry (MRDR), Chair of the HSANZ Myeloma Specialist Practice Network (M-SPN) and Past President and co-founder of the HSANZ Nurses Group. Most recently Tracy has been invited as a member of the IMF Nurse Leadership Board (NLB) and leads the nurse’s program development and delivery during the International Myeloma Workshop (IMW). Tracy completed a master’s in nursing leadership and is currently a PhD candidate at Sydney University. She was awarded the Outstanding Research Achievement Nursing & Midwifery Award 2019 by Sydney Local Health Network (SLHD) for her leadership and research in better understanding the experiences of those affected by myeloma taking high dose steroids and the role of patient reported outcome measures (PROM).
Frailty Assessment in Multiple Myeloma
Findings from a recent inquiry
Alicia Snowden1 and Tracy King2
To download a copy of this article, click here
1Haematology Nurse Consultant, Precision Haematology, East Melbourne.
2 Myeloma Clinical Nurse Consultant | Clinical Research Fellow | PhD Candidate, Institute of Haematology, Royal Prince Alfred Hospital, Sydney.
Fit and frail are terms increasingly used in consensus guidelines for the treatment of multiple myeloma (MM). An individual patients’ fitness often informs treatment choice, dose, schedule and duration, and a range of frailty assessment tools exist to help us measure for this construct. Furthermore, we know that treatment outcomes differ between frailty groups. But what do we mean by ‘FIT’ or ‘FRAIL’, which are the best tools to measure for it, and how do/can we put frailty assessment into practice? These were the questions recently put to members of the Myeloma Specialist Practice Network (M-SPN) and the findings are presented in this short summary article.
When asked if they undertook routine frailty assessment in their MM clinical practice it became clear a range of practices and assessment types were utilised. From ‘end of the bed clinical judgements’ to formal ‘comprehensive geriatric oncology assessment (CGA),’ with most, somewhere in between.
Myeloma – the context
Myeloma is predominantly a disease of older age, with a mean age at diagnosis of 70.2 years, 40% of patients > 75 years and 26% >80 years of age (AIHW 2019). With improvements in overall survival (OS) for those with MM and an ageing of the population we expect to see more cases of MM being diagnosed each year. Myeloma commonly follows a multiply relapsing and remitting course with patients requiring successive lines of multi-drug therapy over increasing number of years. Recent approval of triplet therapy bortezomib, lenalidomide and dexamethasone (VRD) in the upfront setting for MM provides us with robust treatment approaches that aim to increase depth of response and further improve survival outcomes. The intensity of treatment needs to be balanced with ability to tolerate both predictable disease and treatment related toxicity. Incidence of toxicity may be similar between age groups, but capacity to tolerate toxicities decreases with increased age (Terpos et al 2015). Whilst transplant eligible and transplant ineligible pathways are established, optimising treatment choice should also be based on formal frailty assessment, tailoring treatment type, dose and schedule to frailty status.
What do we mean by frailty?
Frailty is a multidimensional state of diminished reserve (energy, physical ability, cognition and health) which gives rise to vulnerability and can result in reduced ability to resist stressors, including cancer and its treatment (Clegg 2013 & Rockwood 2005). Understanding the domains of vulnerability (frailty, comorbidity and disability) is essential in tailoring treatment that will optimise outcomes for individual patients.
How can we measure for frailty?
While there is no shortage of frailty tools, not all are formally validated and there appears a lack of consensus in how and when to use them. Whilst objective frailty assessment informs treatment choice, a range of other factors such as processes of care (number of hospital visits, travel, route of administration, financial concerns) and patient choice, are also taken into account.
Frailty Assessment Tools in Multiple Myeloma
Tool
Factors reviewed
Comments
IMWG Frailty Index
www.myelomafrailtyscorecalculator.net
Age
Activities of Daily Living (ADL)
Instrumental Activities of Daily Living (IADL)
Charlson Comorbidity Index (CCI)
www.mdcalc.com/charlson-comorbidity-index-cci
MM specific tool. Incorporating assessment of comorbidities alongside daily functioning. Widely reported in MM studies, online calculator available, relatively quick.
Revised Myeloma Comorbidity Index
(R-MCI)
www.myelomacomorbidityindex.org
KPS
eGFR
PFT
Fragility
Cytogenetics
MM specific tool. Incorporating additional biological markers and performance measure.
Mayo Frailty Index
ECOG PS
NT-Pro-BNP
MM specific tool. Simple, objective tool, predicts survival independent of age and performance status.
UK Myeloma Research Alliance Risk Profile (MRP)
WHO PS (ECOG)
ISS
CRP
MM specific tool. Objective markers, quick to complete.
Comprehensive Geriatric Assessment (CGA)
Comorbidities, functional status, medications (including polypharmacy and inappropriate medication), cognition, psychological status, social support.
Generic tool, comprehensive but complex to undertake and time-consuming
ADL Activity of Daily Living, IADL Instrumental Activity of Daily Living, CCI Charlson Comorbidity Index, KPS Karnofsky Performance Status, eGFR estimated glomerular filtration rate, PFTs pulmonary function tests, ECOG-PS Eastern Cooperative Oncology Group performance status (also known as WHO PS) NT-proBNP N-terminal natriuretic peptide type B; ISS International Staging System; CRP C-reactive protein
Why should we measure for frailty?
Frailty assessment aims to identify patients with increased care needs or vulnerability that allows clinicians to individualise treatment approaches (choice of drug combination, dose and scheduling) so as to improve outcomes. The most recent Clinical Practice Guideline: Multiple Myeloma (Quach & Prince 2019), Myeloma Scientific Advisory Group (MSAG) lists frailty separately from age, comorbidities and disability, with frailty “variously defined as poor endurance, weakness and low physical activity” (p24). The guidelines provide recommendations for the assessment of suitability of elderly patients for the intensity of therapy, suggesting clinicians determine patient ‘fitness’ (fit, intermediate, frail) so as to inform treatment choice.
In the upfront setting, induction therapy followed by autologous stem cell transplant (auSCT) results in superior survival but can be hard to tolerate due to predictable treatment related toxicities, particularly in those > 70 years of age or with existing comorbidities. Furthermore, patients categorised as frail are more likely to experience grades 3-4 non-haematological toxicity of therapy, early discontinuation of treatment and a shorter OS (Palumbo et al 2015). Determining eligibility for transplant is arguably the most commonly utilised frailty assessment time point. In addition to informing transplant eligibility, frailty assessment can also inform treatment approaches, dose-attenuation and schedule changes with recommendations listed in the Clinical Practice Guideline Myeloma (Quach & Prince 2019 p24-27).
Frailty assessment in clinical practice: M-SPN members experiences
Myeloma Specialist nurses are well placed to screen for and implement frailty assessment in MM. The nurse-patient relationship can enable comprehensive patient assessment that can be hard to achieve during busy Specialist consultations. Frailty assessment and screening can provide additional information on functional or psychosocial status that may impact treatment tolerance.
The Myeloma Specialist Practice Network (M-SPN) identified variation in practice around frailty screening as a good opportunity for the group to review practices in our region. A brief email was sent out to members inquiring of their utility of frailty assessment in routine practice. Feedback was consistent across both public and private settings; while awareness of frailty measures existed, the utility of them was inconsistently applied. Approaches were admittedly ad-hoc, with medical prescriber discretion at its core. The exception was in speciality settings within MM, such as transplant centres where the Haematopoeitic Cell Transplantation – Comorbidity Index (HCT-CI) was commonly used by Transplant Nurse Coordinators pre-auSCT work-up. Other centres utilised the IMWG Frailty Index to assess newly diagnosed MM for transplant eligibility. Formal assessments using a recognised tool were also driven by study participation (e.g. ALLG/AMaRC study ‘Frail M’). The team at Barwon Health conducted a retrospective audit that looked at efficacy and safety of auSCT in elderly myeloma patients aged >65years (Er. J et al 2018). The study found the Revised Myeloma Comorbidity Index (R-MCI) tool to be useful in predicting survival in their patient population.
Other centres are incorporating systematic frailty assessment into standard MM care pathways. We identified a hospital who had embedded frailty assessment into the position description for a new MM Nurse Specialist role. They argued frailty assessment as a mechanism to identify patients at increased risk of poorer outcomes by measuring unfavourable frailty scores, optimising management of existing, undiagnosed or high risk co-morbidities, and assessing for psychosocial needs, amongst others. This is turn potentiates frailty reversibility, mitigates toxicity, prevents unplanned hospital admissions, improves therapy adherence, and enables continuation of therapy.
What are some of the challenges for frailty assessment in routine practice?
Formal assessment vs clinical judgment
Belotti and colleagues (2020) recently compared formal frailty assessment (IMWG frailty index) with clinical judgement in MM patients 65-75yrs being considered for auSCT and found similar outcomes between assessment type. This perhaps emphasises the role of clinical judgement within a multidisciplinary, patient-centred care environment as part of assessment of fitness for treatment.
Reproducibility & Reversibility
Completion of frailty assessment also involves clinical judgement, in part subjective, where assumptions can impact scoring. Robust assessment may also depend on the clinician’s experience in the care of the elderly. Factors assessed such as weakness, malnourishment, and physical endurance are modifiable especially with allied health input. Frailty scoring may therefore change over time. Furthermore, frailty scores in myeloma are commonly reported as they correlate with poor survival outcomes. Future studies could explore frailty assessment and its role in measuring ability to tolerate a treatment regimen not only for duration of therapy but its association with toxicities and impact on health-related quality of life.
Awareness
Traditionally, academic conversations on frailty that explore ‘when is less more?’ are found in Palliative Care or Geriatric Journals, which silos frailty away from academic reviews on optimal treatment found in mainstream myeloma literature. The Paper by Murillo and colleagues (2018) discussing the credentials of the IMWG’s frailty score is found in the Journal of Geriatric Oncology, not in a haematology journal.
Tools are tools.
Tools exist to guide, inform, qualify, and strategize. Perhaps the lack of widespread, routine frailty assessment we found in our brief review, indicates that clinical judgement has been working to date? Assessment of suitability of elderly MM patients for intensity of therapy is complex. Whilst frailty assessment is an important component of identifying appropriate therapy for an individual patient, treatment decisions are made within a complex patient-centred paradigm, that considers a broader range of issues, not restricted to those listed within frailty tools. Furthermore, frailty assessment is a process to be undertaken over time and not only at diagnosis. Formal frailty assessment can inform treatment choice but also guide referral for assistance with modifiable health and lifestyle factors which aim to improve health, reduce frailty and possibly re-inform treatment choice.
Concluding comment
Assessing frailty in myeloma is not a new concept, nor is there a lack of tools to do so. With an increasing number of therapies available to treat myeloma, and a treatment trajectory of successive lines of therapy over increasing number of years, continued improvements in survival will require patients to tolerate more therapies over longer periods of time. Whilst formal frailty assessment has a role in optimising intensity of therapy it can occur alongside clinical judgment within a multidisciplinary framework of patient-centred care. Frailty evolves, and so must our approach to individual assessment.
References
HSANZ-NG publishes a quarterly newsletter, which can be downloaded below.
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