Page 37 Complete Your CE Test Online - Click Here patient to bring up sexual changes rather than asking the patient about their sexual concerns [249]. In premenopausal women, cancer treatment (surgery, radiation, or chemo) can cause precipitous menopause, with symptoms like sudden onset of dyspareunia, decreased libido, vaginal dryness, mood swings, fatigue, and other effects, with little time to adjust to them. The anti- estrogen drugs used to treat breast cancer only serve to heighten these symptoms for many women [249]. Men treated for prostate cancer often have erectile dysfunction, dry ejaculation, some degree of urinary incontinence, and penile shortening. These effects are more immediate with prostatectomy, developing more slowly with radiotherapy. Hormonal therapy for prostate cancer can lead to hot flashes, weight gain, osteoporosis, low libido, and depression [37]. Nurses are not likely to be able to perform an in-depth assessment of sexual concerns and function. But nurses should at least ask about concerns or problems related to sexual dysfunction, and refer the patient and sexual partner to a therapist with expertise in sexuality and cancer [249]. Cancer impact on the patient and family Emotional effects on the patient and family Cancer is a dreaded diagnosis. Its mention, even to people without cancer, prompts recollections of stories about people who had awful experiences with cancer, or who died from it. Even people with early stage cancer and excellent prognoses can feel very anxious, fearful, and vulnerable at times. It is well known that treatments can be arduous, with painful emotional fallout for patients, families, and loved ones. The financial impacts, which are rarely discussed, can affect families’ financial security for many years. Among the long-standing issues familiar to oncology nurses are the life disruptions that cancer brings as well as the emotional effects on the entire family and support systems and the patient who may be facing mortality for the first time. The patient and his or her loved ones may be dealing with the effects of cancer on: family and friend relationships or spiritual crises. Patients may be learning that they need a lot more emotional and logistical support than before. And patients often go through the slow-motion roller coaster of denial, shock, anger, sadness, despair, and many other emotions as they work their way through the minefield of mourning and learn to accept the changes and losses as they adjust to the “new normal” in their lives. Some seem to accept a cancer diagnosis calmly, trying to keep the effects to a minimum. It is not safe to assume that all is well just because a patient “looks OK,” as even these people often are working hard to keep a brave face while they privately worry over what will happen to them and their loved ones. It is acceptable to offer patients an ear if they need one, but some do not want to be pushed to talk about it. On the other hand, complimenting “strength” may backfire, as patients may feel the need to remain stoic even when they need help. There are no guarantees with cancer, and its uncertainties are hard to live with. This sometimes means the nurse’s role entails patience, empathy, promotion of healthy coping, and sometimes referral for specific types of help. With patients who have misconceptions, nurses can be a caring listener as well as a source of accurate information that can alleviate some of the fears and uncertainties. Financial impact Cancer can cause loss of income as a person must cut back their working hours or become unable to work while and medical bills begin. Unfortunately, people who are uninsured have trouble with medical bills much more often than those with health insurance. That is why most people work to keep health insurance. Often, a plan is not enough for many people with cancer, as health insurance can be no guarantee of financial well-being. According to the Kaiser Family Foundation, medical debt triggers many types of hardship and financial instability, and can have serious and long-term consequences. People often cut back on necessities, like food, clothing, and household expenses, but the costs may still exceed what they can pay. Collection agencies can become involved, and lowering credit scores so that qualifying for needed medical loans to help pay for treatment becomes very difficult or impossible. Even if a loan is approved, interest rates are usually much higher, which increases the spiral of financial distress. Sometimes these “hits” on a person’s credit score cause trouble with acquiring a new job after treatment, car loans, or utilities as well as causing difficulties in other situations in which credit histories are checked. These problems can follow a family for many years after cancer treatment is completed [242]. During and after treatment, people may resort to borrowing money from family, taking out second mortgages on their homes, and raiding retirement funds. These actions may help in the short term, but contribute to financial instability later as these may lead to loss of a home, inability to retire, and complicated relationships with family members. Discussing cancer treatment costs with patients can be difficult, which may be one of the reasons it is not done often enough. While more than half of cancer patients want to discuss costs with their doctors, more than 80% do not. Patients often have more concerns about effectiveness than cost; patients sometimes do not want to consider costs when making decisions about treatment. They might not want their doctors to consider costs out of fear that the plan chosen partially because of low cost might be substandard or less likely to be effective. The patient might also feel embarrassed to ask about costs and concerned about the discussion taking up too much of the doctor’s time. But if the patient brings up costs after treatment is begun, there is no chance of reducing the out-of-pocket cost for the patient. Once financial distress has begun, patients sometimes become non-adherent to drug regimens, avoid recommended procedures, and skip doctors’ appointments to save money. This can cause serious health problems in the long term [307]. The patient and family may also lose housing and financial security in the future because of the expenses involved in cancer care. Bankruptcy due to medical expenses is getting more common. People report feeling shame and frustration at not being able to pay their bills. Nursing leadership consideration: To help everyone learn more about financial effects, nurses who work with hospitals and treatment centers that use electronic Patient Reported Outcomes (PROs) can request that they add financial distress along with the other outcomes such as nausea, neurologic side effects, and fatigue [307]. The nurse can ask the patient and family about financial concerns. One way to open the discussion is to ask whether a patients and caregivers are worried about how the costs of cancer treatment are affecting the ability to support themselves or their family. Or inquire if they are concerned about their financial future due to cancer treatment costs. Patient costs can often be reduced without sacrificing quality of care. This is an important message for patients with financial concerns. Depending on the patient’s concerns and priorities, the nurse can encourage discussions with the oncologist about treatment goals and different options that might work for the patient. It is important to be sure that the patient is empowered to ask about the purpose of a medicine or procedure, and exactly how it is expected to contribute to the patient’s quantity and quality of life. Many patients would be surprised to know that for some of the newer and very expensive cancer drugs, studies have only documented a median of an extra couple of months of life (sometimes less) above the older treatment regimens [48]. On the other hand, some of the new drugs offer a median survival improvement of two years or more for those who can afford and tolerate the drug. Another reason for the expensiveness of new drugs is side effects. For example, a drug may costs 50 times more than the drug that it is designed to replace, and not work any better; however, the new drug may have a smaller incidence of a certain side effect. Doctors have the option of trying the older drug to find out if that effect is a problem for the patient before switching to the newer and more expensive one [48]. Choosing drugs that can still meet the patient’s needs and cost less money requires the active assistance of the doctor or care provider. This is a highly personal decision, which greatly depends on the patient’s medical situation. A very expensive drug may be worthwhile to some people because of the expected benefit, but not so much for others.