Running head: VASOMOTOR SYMPTOMS

Management of Vasomotor Symptoms in Breast Cancer Survivors: EBP and Research Study Hollis Misiewicz NURS 916

VASOMOTOR SYMPTOMS Management of Vasomotor Symptoms in Breast Cancer Survivors: EBP and Reasearch Study Vasomotor symptoms, such as hot flashes and sweating, are common among

postmenopausal women and can interfere with activities of daily living and sleep, compromising quality of life. Women who have been treated for breast cancer often experience more frequent, severe, and longer lasting hot flashes than healthy postmenopausal women (Biglia et al., 2009; Frisk et al., 2008). Oncology nurse practitioners and oncology nurses provide care to cancer survivors and knowledge in managing these vasomotor symptoms is essential. The purpose of this paper is to address the design of the problem of determining appropriate interventions for the management of vasomotor symptoms in the breast cancer survivor population as both a research study and an evidence based practice (EBP) project. Definition of Problem Hot flashes are the most common vasomotor symptom that occurs after a woman reaches menopause. Frequent and intense hot flashes can cause depression, interfere with sleep and decrease the quality of life (Mariani et al., 2005; Nedstrand, Wijama, Wyon, & Hammar, 2005). This problem is even more pronounced among women who have been diagnosed and treated for breast cancer. Treatment with chemotherapy can induce premature menopause. Tamoxifen and aromatase inhibitors, used for both premenopausal and postmenopausal women as adjuvant treatment of hormone dependent breast cancers, induce hot flashes that are more numerous and intense than those experienced in the course of normal menopause (Morales et al., 2004). Estrogen and progesterone supplementation has historically been the most frequent treatment for the vasomotor symptoms experienced by healthy postmenopausal women with an 80-90% reduction in hot flashes (Biglia et al., 2009). This intervention is considered inappropriate for the

VASOMOTOR SYMPTOMS management of menopausal symptoms in breast cancer survivors, particularly those with hormone dependent tumors, because of the risk of tumor recurrence (Biglia et al., 2005). Oncology nurse practitioners and oncology nurses alike are often involved in the care of cancer survivors. Assisting patients suffering from the sequelae of cancer treatment is an important part of this care. For breast cancer survivors, management of vasomotor symptoms, most notably, hot flashes can increase the quality of life for these women. A vast array of recommendations exists for decreasing hot flashes, some merely folklore and some based on research evidence. For the nurse to effectively treat patients suffering from the debilitating effects of menopausal vasomotor symptoms it is necessary to examine the evidence as it currently exists to determine the best plan of care. Evidence Based Practice

Evidence based practice encompasses the best available scientific evidence with the best available experiential evidence and takes into account the experiences of both the practitioner and the patient (Newhouse, 2007, p. 433). In considering EBP for the management of vasomotor symptoms of breast cancer survivors a literature search for interventions that have been investigated would be the first step in order to determine what treatments may be effective. Any hormonal therapies would be eliminated. This would narrow the focus of the EBP. The question: What non-hormonal interventions will decrease the incidence and severity of hot flashes of breast cancer survivors? Pharmaceutical and non-pharmaceutical treatments would be considered in the literature review. After examination of the literature the intervention that was shown to be most effective would be recommended to patients complaining of debilitating hot flashes. Results would be evaluated by the subjective observations of the patients following implementation of the chosen treatment.

VASOMOTOR SYMPTOMS Research Study After a review of the literature as a result of an EBP study an intervention that was

deemed to be effective but needed further investigation would be considered for a research study. The research question to be considered would be: Will women who are breast cancer survivors experiencing debilitating hot flashes receiving venlafaxine experience fewer and less severe hot flashes than women receiving placebo? A sample of breast cancer survivors would be randomly assigned to either a treatment group receiving daily venlafaxine or to the placebo control group. The study would be double-blinded to both evaluator and participant. Baseline data in severity and frequency of hot flashes would be obtained in both groups through use of a hot flash diary for one week before beginning the intervention. Post-intervention data would be obtained at appointed times after beginning the treatment and the information obtained in the daily hot flash diary quantified and compared to pre-test information. Data would be analyzed using paired and independent t-tests to compare differences between and within the two samples. Conclusion Breast cancer survivors can experience a diminished quality of life secondary to the onset of severe vasomotor symptoms (Mariani et al., 2005; Nedstrand et al., 2005). It is within the realm of the oncology nurse practitioner and oncology nurses to minimize these symptoms that are the result of anti-cancer therapies. In order to provide the best care the nurse must be aware of what scientific evidence determines is the best intervention and utilize this information in context with the patients circumstances. This evidence can best be obtained by a thorough EBP project. Gaps in the evidence as established by this EBP project would then determine the direction of scientific research studies to bridge the deficit of knowledge.

VASOMOTOR SYMPTOMS References Biglia, N., Sgandurra, P., Oeabi, E., Narance, D., Moggio, G., Bounous, V., Tomasi Cont, N., Ponzone, R., & Sismondi, P. (2009). Non-hormonal treatment of hot flushes in breast cancer survivors: gabapentin vs. vitamin E. Climacteric,12, 310-318. doi: 10.1080/13697130902736921 Biglia, N., Torta, R., Roagna, R., Maggiorotto, f., Cacciari, F., Ponzone, R., Kubatzki, F., &

Sismondi, P. (2005). Evaluation of low-dose venlafaxine hydrochloride for the therapy of hot flushes in breast cancer survivors. Maturitas,52, 78-85. doi: 10.1016/j.maturitas.2005.01.001 Frisk, J., Carlhall, S., Kallstrom A.C., Lindh-Astrand, L., Malmstrom, A., & Hammar, M. (2008). Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicenter trial, Climacteric, 11, 166-174. doi: 10.1080/13967139801958709 Mariani, L., Quattrini, M., Atlante, M., Barbati, A., & Giannarelli, D. (2005). Hot-flashes in breast cancer survivors: effectiveness of low-dosage fluoxetine. a pilot study, Journal of Experimental and Clinical Cancer Research, 24(3), 373-378. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16270523 Morales, L., Neven, P., Timmerman, D., Christiaens, M., Vergote, I., Van Limbergen, E., Carbonez, A., Van Huffel, S., Ameye, L., & Paridaens, R. (2004). Acute effects of tamoxifen and third-generation aromatase inhibitors on menopausal symptoms of breast cancer patients, Anti-Cancer Drugs, 15, 753-760. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15494636

VASOMOTOR SYMPTOMS Nedstrand, E., Wijma, K., Wyon, Y., & Hammar, M. (2005). Vasomotor symptoms decrease in women with breast cancer randomized to treatment with applied relaxation or electroacupuncture: a preliminary study, Climacteric,8, 243-250. doi: 10.1080/13697130500118050