Page 19 Complete Your CE Test Online - Click Here symptoms of contagious illness to cleaning blood glucose monitors. All of these standards are important to patient (and staff) safety. Safety note: Always know the basics of a facility’s infection control plan and how to contact the infection control coordinator at all times. The plan should meet the standard of care, be regularly updated, and be consistent with CDC recommendations, both for the safety of the care providers and the patients. Even though the nurse is typically not the one writing the prescriptions, nurses are licensed professionals with a scope of practice for which they are responsible and even liable. As such, nurses must know if the prescription or order is safe and appropriate for the patient: for example, if it is the right drug for the patient’s condition; if it is within the correct dosage range; if the drug might worsen the patient’s condition; likely side effects; and that it is not contraindicated for any reason. Given its expansion, there has been special attention to quality of care in outpatient oncology practices. In 2010, the American Society of Clinical Oncology (ASCO) launched an initiative to recognize oncology and hematology-oncology practices that were committed to offering quality cancer care. The Quality Oncology Practice Initiative (QOPI) Certification Program (QCP) evaluates the performance of outpatient oncology or hem-onc practices in areas that affect patient care and safety. The QCP is a voluntary program that is based on the ASCO/ONS standards for safe chemotherapy administration. It certifies and enables practices to evaluate and improve the quality of care provided. Since the initiative began, a good deal of observation and research on quality care and documentation in outpatient settings has been published. Calls have also been issued to standardize reporting and tracking of chemotherapy errors and events. With data on the types of events that occur, it becomes possible to design new safety measures and prevention methods. No matter the setting, the nurse is responsible for safe handling of chemotherapy and other drugs. Home care nurses should be sure that patients know how to safely handle and dispose of chemotherapy at home. This can be a challenge when juggling ways to promote adherence to home medications; this can often mean leaving reminders in visible locations and ensuring drugs are out of the reach of children and pets. Frequent follow-up, assessments, and check-ins are necessary to find out whether there are adherence problems or complications that could cause serious problems so that interventions can happen quickly. To remain competent and effective in the complex realm of oncology, nurses must actively keep informed on standards of care, changes in practice, guidelines for cancer care, drug dose ranges, medication toxicities, and an ever-changing array of equipment. According to the Oncology Nursing Draft Standards of Oncology Nursing Education, nurses must become and remain lifelong learners. Preparing for treatment: Pregnancy, fertility, and conception Treatment risks associated with pregnancy, fertility, and conception must be addressed for women of childbearing age as well as men who might want to father a child before cancer treatment begins. Many cancer treatments can harm the fetus, damage sperm, or cause temporary or permanent infertility. Pregnancy during cancer treatment Cancer during pregnancy is fairly rare, occurring more often in cancers that occur at younger ages. For example, breast cancer occurs in approximately 1 in 3,000 pregnant women. Overall survival may be worse in these cases, possibly because of delays in diagnosis. Cervical cancer is also sometimes discovered during pregnancy. Although early stage disease can be treated during the second trimester, more advanced disease (Stages II to IV) is problematic because treatment is needed right away, and the usual treatment (radiation) is toxic for fetuses. Neoadjuvant chemo has sometimes been offered to pregnant women with locally advanced disease after the first trimester, with surgery or radiation after delivery, but data are lacking on long-term outcomes for the mothers, so it is unknown if this may pose more risk to the woman. Avoiding pregnancy Women of childbearing potential are typically tested for pregnancy before radiation therapy or chemotherapy is started, and effective birth control must be used throughout and for some months after treatment in order to avoid fetal damage from teratogenic or mutagenic effects of the radiation/chemo or other harmful effects. Little is known about effects on the fetus when men conceive during or soon after radiation treatment or chemo, but men are also typically advised to avoid conception during and for some months after treatment. Women who are found to be pregnant before they start cancer treatment may still be able to have their cancer treated, but it must be carefully timed and based on how far along the pregnancy is; the type, location, and stage of the cancer; and the woman’s wishes. The kinds of treatment with less fetal effect (such as surgery) may be done in early pregnancy, and some cancer treatment drugs can be given later in the pregnancy (after the first trimester), although they can restrict fetal growth and cause premature labor. It is best to work with an oncologist with some experience at treatment during pregnancy involved early in treatment planning. Breastfeeding is generally not recommended during chemotherapy because drugs can be secreted in the breast milk that could affect the infant. Fertility Women Women tend to have a more demarcated window in which they can bear children; however, it is still best to ask about future childbearing plans before treatment begins. Many types of cancer treatments carry the risk of infertility, but this varies by age, location of the cancer, and treatment regimen. Bone marrow and stem cell transplants usually cause infertility because of the pretransplant regimen. Especially in women older than 35, cancer treatment drugs can cause early ovarian failure with permanent infertility. In young women, there may be amenorrhea that reverses after treatment with return of fertility, but they may still go on to have premature menopause. It is also important that women understand, that during treatment, menses do not always indicate fertility, as women can have menses while infertile; a woman can be fertile even when experiencing what appears to be amenorrhea. FSH levels are helpful in determining fertility after treatment. As noted earlier, pregnancy during most cancer treatments is not recommended and birth control is required even during times the woman is not having menses. Drug effects on fertility are often very hard to predict for any one woman, so women who know they want children despite chemotherapy may want to go ahead with cryopreservation of fertilized eggs unless they have religious or ethical objections to embryo preservation. Insurance does not always cover this procedure, which can be expensive. Women who object to embryo preservation or who do not have a male partner or sperm donor can opt to have unfertilized eggs frozen, but egg banking is a newer procedure. Because the eggs of younger women are more likely to be healthier and more plentiful, some centers have an upper age limit in the mid-30s for egg freezing. This procedure should be done in centers with a record of experience and success. There are also investigational procedures, like partial removal of the ovary for freezing, but the evidence to support this procedure is sparse. Insurance companies rarely cover these kinds of procedures, and they can be costly. Maintaining frozen tissue (e.g., embryos, eggs, or ovarian tissue) involves annual fees. Pelvic or abdominal radiation can cause ovarian failure if enough radiation reaches the ovaries. Sometimes the surgeon can relocate the ovaries so that they are out of the radiation field, which improves the chances they will continue to function. However, radiation can cause uterine fibrosis as well so that the uterus cannot expand enough for a full-term pregnancy. Radiation to the brain can affect the pituitary gland, which can in turn interfere with hormonal signals to release eggs. Hormone therapy for hormone-receptor-positive breast cancer is available to premenopausal women (e.g., tamoxifen) and is usually continued for five or more years after treatment, but this is contraindicated in pregnancy. Premenopausal women must use careful