Pamela Matten, RN, BSN, OCN Karen Overmeyer, MS, RN, ANP

1. Enhance Your Thoracic Oncology Program Through Prevention and Screening Pamela Matten, RN, BSN, OCN Nurse Navigator Thoracic Oncology Program The Center for Cancer Prevention & Treatment St. Joseph Hospital

4. Objectives Purpose and history of lung screening Findings of the National Lung Screening Trial (NLST) Navigators’ role in screening Developing a successful computed tomography (CT) lung screening program Role of the multidisciplinary conferences and screening Prevention; smoking cessation

5. Why Is CT Lung Screening So Important? Lung cancer, as the most lethal cancer in the world, presents an enormous health care challenge. However, the key to reversing the situation may be in embracing a public health sensibility in harnessing the power of CT imaging in a carefully validated approach to the early management of lung cancer. - AK Ganti, 2006

6. National Lung Screening Trial New clinical evidence from the NLST indicates “Screening with the use of low-dose CT reduces mortality from lung cancer. The rate of death from any cause was reduced in the low-dose CT group, as compared with the radiology group.” National Lung Screening Trial. 2011.

7. 14th World Conference on Lung Cancer “This is the most important publication in lung cancer in a decade.…We can expect to see a shift in lung cancer, with changes in management that hail a new era in lung cancer treatment.…We are on the crest of a wave of an enormous change in lung cancer.” - Dr. John Field, Chair, International Association for the Study of Lung Cancer CT Screening Task Force

8. Pertinence for Today When guidelines for screening are established, patients will be looking to their community hospitals for screening programs The thoracic nurse navigators’ role, experience and ability to act as liaison between patient and physicians, makes them ideal candidates to implement and manage a CT screening program

9. Purpose for Screening Key to saving lives Find lung cancer early Surveillance of suspicious nodules Lung cancer screening provides a teachable moment for promoting smoking cessation and relapse prevention1 Helps grow your thoracic oncology program 1ParkER, et al. Ann Behav Med. 2009;37(3):268-279.

10. History of CT Lung Screening 1970-1980: Studies of chest x-rays disappointing for people considered high risk for lung cancer; CT introduced CT scanners gradually became widely available In 1991, radiology researchers led by Claudia Henschke, MD, began investigating the potential of CT scans to provide the screening benefit that chest x-rays failed to show

11. International Early Lung Cancer Action Program (I-ELCAP) Ongoing observational study and research program initially started in New York state 50,000+ participants/13 states/8 countries Purpose: Assess impact of CT lung screening and improve protocol Results: Participants with stage I cancer with surgical resection within 1 month of diagnosis had survival rate of 92% Criticized because it did not address a mortality benefit from lung cancer screening www.ielcap.org/

12. National Lung Screening Trial Launched in 2002 by National Cancer Institute Goal to determine if CT scan could reduce number of lung cancer deaths by at least 20% Recruited 53,000+ current and former smokers aged 55 to 74 who smoked for 30 pack-years Half screened with chest x-ray, half with CT scans Trial stopped 2 years early in 2010 when observers discovered there were already 20.3% fewer lung cancer deaths with CT scan www.cancer.gov/clinicaltrials/noteworthy-trials/nlst.

13. NLST Results in Perspective: A Comparison of Mortality Benefit NLST results: 20.3% This is extremely significant Mammography screening: 15% PSA testing: 0% in US trials; 20% in Swedish trial www.cancer.gov/clinicaltrials/noteworthy-trials/nlst.

14. What About False Positives? A comparison of x-ray vsCT suggests the magnitude of over diagnosis with low-dose CT compared with radiographic screening is not large 10% to 30% of those screened for cancer will have a positive screen requiring further testing 13% of those screened using the I-ELCAP protocol will have a positive screen

15. What About Other Screening Methods? Blood, urine, breath, or sputum or genetic link? Research is ongoing to find biomarkers that could uncover a genetic clue that a person is predisposed to lung cancer This is harder than we thought and may take decades to realize Currently no other method of screening for lung cancer has been found to be effective

16. What About Radiation Exposure? “…the decrease in the rate of death from any cause with the use of low-dose CT screening suggests that such screening is not on the whole deleterious”1 Screening CT delivers exposure to 0.3 to 0.55 mSvof radiation, which is the equivalent of 2 chest x-rays2 or 1-2 mammograms3 The potential problems can be safely managed with adherence to a well developed protocol for the screening, diagnosis and treatment of early lung cancer 1NLST Research Team. N Engl J Med. 2011;365:395-409. 2Diederich S, et al. Cancer. 2000;89:2457-2460. 3Brenner DJ, et al. Radiology. 2004;232:735-738. ..

17. Fleischner Society Guidelines

18. Multidisciplinary Conference: A Great Venue for Presenting Abnormal Screening CTs

19. Case Study 64-year-old woman with chronic smoking history >20 pack-years Referred by primary care physician (PCP) for CT screening Screening revealed a 2.13-mm spiculated nodule Radiologist recommends follow-up with diagnostic scan in 1 year

20. Original CT Screening

21. Repeat CT Scan 14 Months LaterNodule 5 mm

22. Presented at Multidisciplinary Conference Nodule increased to 5 mm Recommendations – surgical consult Surgeon is cautious since nodule is so small – wait 3 months then repeat CT

23. Repeat CT 4 Months LaterNodule 6.65 mm

24. Case Study Conclusions Minimally invasive video-assisted thoracoscopic surgery (VATS) 3 days in hospital Pathology; 7 mm adenocarcinoma Patient referred to postoperative physical and respiratory rehabilitation 3x times 3 weeks Surveillance CT every 6 months for 1 year and every year thereafter

25. Developing a CT Screening Program The thoracic nurse navigators’ role, experience and ability to act as liaison between patient and physicians, makes them ideal candidates to implement and manage a CT screening program Nurse navigators are directly involved in development and enhancement processes aimed at improving clinical outcomes for oncology patients. The nurse navigator educates patients about cancer prevention, screening, diagnosis, treatment options, and the importance of early detection of cancer

26. How Do You Start? Build your team Determine the costs Set screening guidelines Capture the data Market the program Overcome challenges

27. Building Your Team Identify a physician champion Nurse navigator is a key element Meet with key players: radiology, reimbursement, billing, administration, legal Give evidence-based facts: Screening Saves Lives Have a clear purpose and vision Develop ownership through brainstorming Each key player implements their piece

28. Nurse Navigator’s Role Act as liaison between patient and physician Implement & manage CT lung screening program Directly involved in program development and enhancement Educates patients about: Smoking cessation Screening results Further work-up/diagnosis Treatment options Importance of early detection

29. Worth the Cost CT lung screening is value added for your program “…the cost of surgery for stage I lung cancer is less than half that of late-stage treatment…”1 St. Joseph Hospital increased analytical cases by 10% each year since starting CT lung screening 1HenschkeCI, et al.ThoracSurgClin. 2007;17(2):137-142.

30. Worth the Cost (cont.) CT lung screening is not covered by most insurance plans, including Medicare Screening needs to be affordable for your patient demographics Consider setting a low cash pay price ($125) No insurance billed Develop a CPT code for the procedure Determine if you will provide financial aid to uninsured

31. Screening Guidelines No national screening guidelines The new data will be reviewed by the US Preventive Services Task Force (USPSTF) in 2012 The American Society of Clinical Oncology (ASCO) is developing clinical practice guidelines on lung cancer screening with the National Comprehensive Cancer Network (NCCN), American Cancer Society (ACS), and the American College of Chest Physicians

32. Screening Guidelines (cont.) Set your criteria for screening based on your demographics Pool the resources of the NLST, I-ELCAP, or other international studies This will help you develop a protocol that will provide patients the maximum benefits from screening with the lowest possible risks When the NCCN guidelines are established, criteria within your screening program can be adjusted accordingly

33. St. Joseph Hospital (SJH) Criteria TOP criteria is similar to the I-ECLAP protocol: Patient must be ≥50 years of age Smoked for ≥20 years Patients should be asymptomatic Have a PCP Have a PCP in Orange County

34. Data Capture Absolutely necessary Develop a CT screening access database Need administrative assistance Letters are generated at 3, 6, or 12 months, as recommended by the radiologist Follow up for 2 years

35. CT Screening Access Database

36. Marketing Develop screening brochures/referral pads See 100 PCPs within first year Educate on importance of early diagnosis for lung cancer and smoking cessation Offer your services Call with suspicious nodule Put them at ease on issue of care Advertise your TOP program Emphasize: “We want to find lung cancer early; when it is treatable and possibly curable”

37. SJH Retrospective Review 526 patients screened from November 2004 through 2008; 3% were diagnosed with cancer 458 patients had abnormal lung findings; 3.5% diagnosed with cancer 16 cancers were identified; 13 were lung primaries and 3 non-lung (B-cell lymphoma, liposarcoma, and metastatic melanoma)

38. SJH Retrospective Review Of the 13 primary lung cancers identified by screening: 77% (10) were stage IA 17% (2) were stage III 8% (1) were stage IV Over 75% were early-stage lung cancer, treated with surgical resection and potential cure

40. Challenges Patient compliance to repeat scans at 3, 6, or 12 months Implement interventional tactics to encourage patient compliance Strategic planning should include expansion and flexibility Ability to modify screening programs as evidence points toward national screening guidelines

41. Screening and Prevention Go Hand-in-Hand

42. Smoking Cessation A cancer diagnosis provides an important window of opportunity for promoting tobacco cessation

43. Why Promote Cessation? A large proportion of cancer patients are current or former smokers at the time of diagnosis Prevalence of ever smoking is highest among patients with tobacco-related cancers 20% to 50% of patients with cancer continue to smoke after diagnosis By not addressing the issue, it sends the message, “It’s too late” or “I don’t care”

44. Further Reasons to Promote Cessation Smoking negatively impacts cancer treatment response Surgery Radiation Chemotherapy Increases odds for development of second primary tumors Negatively impacts survival outcomes Reduces quality of life

45. Develop a Smoking Cessation Program Obtain a Tobacco Treatment Specialist (TTS) certification: http://ndc.mayo.edu Develop curriculum: Mayo Clinic and Rx for Change (UCSF) Purchase CO monitor Resources: www.rxforchange.com www.becomeanex.org www.testbreath.com

46. Classes Initial consultation with the Tobacco Treatment Specialist (45-60 minutes) Follow up at 1, 3, and 6 months through e-mail Billed as “incident to”: ICD-9 code 305.1 Tobacco Use Disorder, CPT code 99407 Tobacco behavior change >10 minutes 5 weekly group classes (2 hours each) - free Develop an Excel database to keep statistics, such as cessation method, quit rate at 1, 3, and 6 months

47. Questions? Pamela Matten, RN, BSN, OCN 1100 W La Veta Orange, CA 92867 714-734-6236 pamela.matten@stjoe.org

48. References Brenner D.J., Elliston C.D. (2004), Estimated radiation risks potentially associated with full-body CT screening. Radiology, 232:735-8. Diederich S, Lenzen H., (2000). Radiation exposure associated with imaging of the chest: comparison of different radiographic, and computed tomography techniques,. Cancer. 2000;89:2457-60. Fleischner Society Guidelines: Radiology 2005 Nov; 237:395-400 Henschke C.I., Yankelevitz D.F., Altorki N.K. (2007); The role of ct screening for lung cancer. J.thorsurg.2007.03.004(141) Ganti A.K.,(2006);Lung cancer screening..The Oncologist.2006.11 (5) 487 MacMahon, H., et al., Guidelines for management of small pulmonary nodules detected on CT scans; A statement from the Fleischner Society. Radiology 2005; 237: 395-400 NLST research team, Reduced lung cancer mortality with low-dose computed tomographic screening. NEJM 2011; 10.1056; 13. NLST research team, Reduced lung cancer mortality with low-dose computed tomographic screening. NEJM 2011; 10.1056; 9-10. NLST research team, Reduced lung cancer mortality with low-dose computed tomographic screening. NEJM 2011; 10.1056; 11. NLST research team, Reduced lung cancer mortality with low-dose computed tomographic screening. NEJM 2011; 10.1056; 1 Park E.R. et al., Risk perceptions among participants undergoing lung cancer screening: baseline results from the national lung screening trial. ANN Behav Med 2009; 37 (3): 268-279.

49. Lung Cancer Case Discussion Karen Overmeyer, MS, RN, ANP Thoracic Oncology Nurse Navigator Henrico Doctors’ Hospital Cancer Center Specialty Clinics Richmond, Virginia

50. Cancer Center Specialty Clinics at Henrico Doctors’ Hospital

51. Objectives Identify 3 risk factors for NSCL cancer. Discuss the implications of molecular studies in treatment planning. Define the difference in prognostic biomarkers v.s. predictive biomarkers. Describe the Nurse Navigator role in the delivery of care to the thoracic oncology patient. Discuss the advantages of multidisciplinary care for the lung cancer patient.

52. Overview of Lung Cancer Today Leading cause of cancer worldwide. > 170,00 death in the U.S. More deaths than breast, colorectal, and prostate combined. 5-yr survival rate for all NSCL stages combined 16%. 5-yr survival rates of unresectable disease in stages IIIB and IV: < 5% American Cancer Society: Cancer Facts & Figures 2010

53. Classifications

54. Case Studies 65 year old African American, male, smoker. 45 year old, Caucasian, female, non-smoker.

55. Case Study #1 Joe 65 y/o African American, married, brick mason. PS = O 40 pack year smoking history, hypertension well controlled, prostate cancer 2008 with post brachytherapy PSA of 0.5 (ng/ml) Presented to PCP w/ bacterial pneumonia visible on CXR w/ dense consolidation RLL. Symptoms do not totally resolve with antibiotics. Repeat CXR 8 weeks later  residual opacity.

57. Case Study #1 CT scan demonstrates a 4 cm spiculated mass in RLL plus enlarged right hilar lymphnodes. RadioGraphics July 2000 vol. 20 no. 4 1182-1185

58. TNM Staging – 7th edition

59. Staging for Lung Cancer What is Joe’s clinical stage? ____________ What is the next step?________________ PET Bronchoscopy Mediastinoscopy EBUS CT guided biopsy Right lower lobectomy Notes: _______________________________________ ______________________________________________________________________________________________

60. Chest Tumor Multidisciplinary Clinic Provides a team approach with disease specific specialists meeting together at one place and time to decide on a comprehensive treatment plan. Goal is to expedite the pathway from suspicion to diagnosis, & diagnosis to treatment, and through survivorship or palliative/hospice while collaborating with PCPs and all involved clinicians. Patient and family remain at the helm of decision-making. Visit to discuss options for further treatment, or proceed on to further testing and come to MDC for diagnosis & treatment planning.

61. History & Physical Exam Review of Systems: HTN well controlled on valsartran /hydrochlorthiazide 160/12.5 No hx of MI or notable CAD. ASA 80mg daily, MVI, Vitamin E Colonoscopy age 55, 2 benign polyps Prostate cancer, annual PSA & exam Denies fever, chills, night-sweats, but admits to intermittent cough, feeling “more winded” , c/o low level fatigue and 3-6# weight loss over the past 4 months. Denies GI, GU, MS, Neuro changes no headaches, visual changes, changes in mentation, falls, lightheadedness.

63. Physical exam:

64. HEENT unremarkable, good dentition.

65. BP 150/88 P82 R20 T98 Ht: 5’ 8” ECOG:0 Pain:0/10

66. Pulse Ox: 99%

67. Lungs clear on left with few rhonchi on the right, no wheezing. No palpable neck, chest, axillary nodes; no pinpoint tenderness over thorax, bony prominences. Skin, extremities unremarkable for bruising, rashes, edema, other.

69. Pathology for Joe CT-guided needle biopsy of RLL mass: Non-small cell lung, adencarcinoma type Moderately differentiated Immunostains –differentiate primary lung from metastatic adenocarcinoma TTF- 1 (+), CK7 (+) , and CK20 (– ) Chromogranin and synaptophysin are negative. Notes: ___________________________ ___________________________________

70. Case #1 Staging Final diagnosis: _____________________ What’s next?_______________________ MRI of brain w/without contrast PET/CT Pulmonary Function Studies/Pulmonary Consult. Cardiology consult. Tobacco addiction counseling. Supportive services (follow up of Distress Screening Tool, PsychoSocioSpiritual, Financial advisor)

71. Final Staging Results PET shows expected FDG avidity in RLL mass with SUV 9. 4, plus 2 right hilar nodes with SUV of 6. Also several mildly positive right and left paratracheal nodes with SUV ranging from 1.5 to 2.8. No extra-nodal or distant metastatic sites evident. MRI is w/o evidence of metastasis. PFTs : FEV1 = 2.48 /FVC % = 58% DLCO =70 What is Joe’s final stage?_______________

72. Treatment Options in NSCL Surgical Resection ____________________ Chemotherapy alone___________________ Chemo/Radiation_____________________ Stereotactic (SBRT) ___________________ Radiation alone ______________________ Do nothing!

73. Joe’s Final Plan of Care Chemo Regimen:_____________________ Rationale __________________________ ____________________________________ ____________________________________ Radiation: __________________________ Rationale: __________________________ ____________________________________

74. Nursing Interventions Knowledge deficit regarding lung cancer Support & ongoing teaching throughout treatment. Assess for depression. Assessment of treatment related toxicities Chemotherapy (nausea/vomiting, oral mucositis, low blood counts, fatigue, neutropenia, thrombocytopenia, anemia, constipation/diarrhea, anorexia.) Radiation – dysphagia, mucositis, pharyngitis, thrush,wt loss, cough increase, skin changes. Monitor side-effects of bevacizumab Hypertension – instruct on home monitoring Infusion reactions – fluid management Cardiotoxicity- chest pain, peripheral edema, CHF

75. Case #2 Patient History Eloise 45 y/o Caucasian, divorced, no children. Never-smoker, active lifestyle, no PMH other than seasonal allergies. PSH: hysterectomy at age 38 for fibroids, no other adult surgeries. 3 month hx of cough, rhinitis, slight fatigue and by month 3, cough worse, experiencing slight shortness of breath, chest pressure with coughing. PS= O

76. Incidence in Never-Smokers Risk factors: Environmental (haloethers, asbestos, arsenic, radon, nickel, polycyclic aromatic hydrocarbons (PAH), secondhand smoke) Genetic, dietary, association w/ other benign lung disease (pulmonary fibrosis, COPD Globally – 15% in men & 53% in women In Asia, 60-70% of cancers in non-smokers are women.

77. CT scan Results -Case Study #2 CT of chest, abdomen, & pelvis revealed a right upper lobe mass, 1.4cm x 1.4cm extending into the pleura. Right hilar mass 4.5cm x 4.3cm, bulky mediastinal adenopathy measuring 3.3 cm x 2cm x2cm, precarinal and pretracheal nodes measuring 5.1cm x 3.5cm x 3.2 cm.

78. Staging for Lung Cancer What is Eloise’s clinical stage? ____________ What is the next step?__________________ PET Bronchoscopy Mediastinoscopy EBUS CT guided biopsy Surgical resection Notes: _____________________________________ __________________________________________________________________________________________

79. Multidisciplinary Clinic ROS negative in all systems except for notable cough and chest discomfort described as tightness all over. The patient works for a local government agency, but drives to a satellite office I hr away each day; works out at the gym 3 days a week, maintains healthy diet and annual checkups. She is divorced x 8 yrs, has a dog, owns her own home, loves gardening, has a sister who is her support system. She is “devastated” and in shock over initial CT findings. Distress screening:___________

80. Multidisciplinary Clinic Physical Exam: VS: 120/72 P78 R18 T98 Ht: 5’6” Wt: 138# Pain: 0/10 ECOG: 0 Pulse Ox: 98% Ambulatory, oriented, talkative, well-developed, well-nourished cauc. Female. HEENT unremarkable; Chest: Bilateral breath sounds diminished toward bases bilaterally with intermittent wheeze; cough induced by deep breathing. HRRR, no murmurs, rubs. No palpable head, neck, chest lymphnodes; no areas of tenderness or masses noted. GI: active bowel sounds, flat abd. , no tenderness, masses, pain to palpation. GU deferred. Skin unremarkable, w/o bruises, rashes; no peripheral edema.

81. A Diagnosis & Next Steps Eloise’s path returns as NSCL, type______ Immunohistochemistry_______________ Molecular profiling: __________________ Chemotherapy + Radiation is planned. What therapy would you offer this patient? Paclitaxel/carboplatin Bevacizumab/pemetrexed/cisplatin Gemcitabine/carboplatin Cisplatin/etoposide

82. Predictive vs Prognostic Markers Predictive – indicates therapeutic efficacy Prognostic – indicates survival independent of treatment received.

83. PET & MRI Results PET: RUL mass has moderate uptake w/ SUV 2.9. Left upper tracheal node has an SUV of 8.6; midline mediastinal nodes are 14.7; right hilar adenopathy SUV is 25. No focal uptake below the diaphragm.

84. PET Scan Results

85. MRI of brain w/ without contrast shows 3 areas of metastasis: right frontal 0.1cm, temporal-occipital lobe demonstrates two lesions 0.9cm and 0.5cm.

86. Staging Now what is Eloise’s Stage?____________ How does this affect treatment?__________ Eloise was holding out hope for consideration in a clinical study, but late one evening she has one episode of hemoptysis which she describes as a teaspoonful of blood mixed with sputum. She is seen and evaluated in the ED and discharged home. She is disqualified for any clinical studies. How does hemoptysis change the planned Tx?______ What should our next first step be?__________

87. Gamma Knife http://www.harperhutzel.org

88. Navigator Interventions Knowledge deficit regarding lung cancer Support & ongoing teaching throughout treatment. Patient and family. Assessment of treatment related toxicities Chemotherapy (nausea/vomiting, oral mucositis, low blood counts, fatigue, neutropenia, thrombocytopenia, anemia, constipation/diarrhea, anorexia.) Monitor side-effects of pemetrexed Maintain folic acid and B12 levels to reduce GI/hematologic side effects -folic acid daily for 5 of 7 days of cycle 1, then daily w/ treatment, and for 21 days post last treatment. B12 one week prior to first cycle, then every 9 weeks thereafter.

89. Additional Interventions: Nurse Navigator promotes ongoing collaboration: Between care providers, referring physician Scheduling follow up testing, appointments Nutritional assessment. Counsel regarding long distance driving No history of seizures Energy conserving daily routines Delegating or hiring assistance with home and yard maintenance. Psychosocial and financial support LINC (legal information network for cancer) local pro-bono defense for workplace rights.

90. Effectiveness of Therapy/Maintenance Eloise is rescanned  good response. Single agent erlotinib is selected for maintenance. Which of the following are associated side effects? Paronychia Keratoconjunctivitis Acneform rash Diarrhea Interstitial lung disease a, c, d all of the above

91. Nursing Interventions Potential disruption of skin integrity r/t side effect of tyrosine kinase inhibitor. Prevent dry skin (adequate hydration, avoid hot baths, protect skin from the elements/injury). Thick emollient to face/body 2-3 x/day. Stay out of the sun; SPF 30 or > sunscreen. Exercise caution with concomitant medications d/t CYP3A4 inhibitors. Consider prophylaxis regimen Doxycycline, topical hydrocortisone 1% STEPP trial 50% reduction of grade 2 or > skin toxicities.

92. EGFR Rash

93. The Good News – New Directions Several days prior to Eloise starting erlotinib, crizotinib is released with FDA approval. 250mg twice per day Reduce to 200mg tab twice per day for side effects Take with or without food Is a CYP3A pathway drug alterations. Monthly CBC, liver enzymes, bilirubin Monitor for: Visual disturbance, nausea, vomiting, diarrhea or constipation. QT interval prolongation Signs of pneumonitis Edema

94. Case #1 revisited Joe, 68 y/o African American Treatment stopped d/t poor tolerance. Presents with dyspnea, cough 5 mos. s/p completion of four cycles of chemotherapy & radiation. Hospitalized during treatment for intractable nausea & for febrile neutropenia. He has Grade III chemotherapy induced neuropathy. What is most appropriate next step? Hospice/supportive care EGFR inhibitor (erlotinib or gefitinib) Docetaxel Pemetrexed

95. Palliative Care: Early Intervention Medical care & Palliative care not mutually exclusive Impact on quality of life and survival Role of nursing as advocates Promote early initiation, at diagnosis Offer patient and family access to resources for advanced symptom control Utilize psycho-social-spiritual support as needs, concerns arise. Poised to assist with the transition to end of life care so that it is not a surprise to arrive at that door.

96. Current & Future Directions “Personalized” therapies – expanding opportunities for growth & development Novel targets in lung cancer Prognostic vs. predictive biomarkers Molecular diagnostics and genomics Prevention and Intervention Tobacco in all forms Environmental controls

97. References Dienstmann, D., Martinez, P., Felip, E. (2011). Personalizing therapy with targeted agents in non-small cell lung cancer. Oncotarget 2011; 2:165 -177. Retreived from: www.impactjournals.com/oncotarget. Subramanian J, Govindan R (February 2007). "Lung cancer in never smokers: a review". Journal of Clinical Oncology25 (5): 561–70. doi:10.1200/JCO.2006.06.8015. PMID 17290066. Malloy P, Virani R, Kelly K, Munevar C. Beyond bad news – commmunication skills of nurses in palliative care. J. Hospice Palliative Nurs. 2010; 12:166 -174. VonHoff, D, Stephenson, J, Loesch, D, et. al. (October 28, 2010). Pilot study using molecular profiling of patients’ tumors to find potential targets and select treatments for their refractory cancers. Journal of Clinical Oncology. http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2009.26.5983 Clinical Practice Guidelines in Oncology:non-small cell lung cancer. (July 2010). Journal of the Comprehensive Cancer Network. Vol 8, Number 7; pp739-832.

98. Karen Overmeyer, MS, RN, ANPThoracic Oncology Nurse NavigatorHenrico Doctors HospitalCancer Specialty Clinicskaren.overmeyer@hcahealthcare.com