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Eating regularly and being as physically active as you are able may help to relieve your fatigue and enhance your mood. Consider a diet that consists of water soluble fibercontaining foods such as bananas, white rice, applesauce, and white toast. These include foods containing nuts and seeds, raw vegetables and fruits, and whole grain breads and cereals. If the medicine is not controlling the diarrhea, call the healthcare professional that prescribed the medicine. Try these ideas for managing fatigue: Temporarily rely on ready-to-eat foods like frozen dinners, fruits, and vegetables. Aim for at least 8 cups of hydrating fluid each day unless advised to restrict fluids for another medical condition. Constipation can be a symptom of the cancer itself or it can be caused by medicines used to treat cancer or manage pain. Constipation is when bowels do not move regularly and when stools become hard and difficult to pass. Try these ideas for managing constipation: Drink more healthy beverages to help keep your digestive system moving, especially water, prune juice, warm juices, decaffeinated teas, and hot lemonade. Increase intake of high fiber foods such as whole grains, fresh and cooked vegetables, fresh and dried fruits, and foods containing peels, nuts, and seeds. Increase your physical activity as you are able, such as taking a walk or doing limited exercise every day. Bowel Changes: Diarrhea and Constipation Diarrhea can be caused by the cancer itself, certain chemotherapy agents and medicines, or because of radiation therapy to the abdomen and pelvis. Try these ideas for managing taste and smell changes: Experiment with temperatures of foods (warm, cool, or icy) to find which temperature is the most soothing. Focus on warm or cool milk-based beverages, non-acidic fruit drinks (diluted if necessary), "flat" carbonated beverages, and cream or broth-based soups. Rinse your mouth several times a day with 1 to 2 ounces of a homemade salt and baking soda solution (one quart of water combined with one teaspoon of salt and one teaspoon of baking soda). Speak with your healthcare professional about medications that can numb or soothe your mouth or throat. Often, moist and naturally sweet foods such as frozen melon balls, grapes, or oranges work well. Try eating cooler temperature foods, rather than hotter temperature foods, as they have less aroma and taste. Red meat often becomes less appealing, so try poultry, fish, beans, nut butters, or eggs. Brush your teeth and tongue and rinse your mouth regularly, especially before eating. Rinse your mouth several times a day with 1 to 2 ounces of a homemade salt and baking soda solution (one quart of water combined with one teaspoon of salt and one teaspoon of baking soda) or an alcohol-free mouth rinse. Unwanted Weight Gain Weight gain can occur during or after treatment for hormone-sensitive cancers such as breast or prostate cancers. In addition, medicines such as steroids used as a part of some cancer treatments can contribute to increased weight. Try these ideas for managing unwanted weight gain: Sore Mouth or Throat A common side effect of certain chemotherapy agents or radiation therapy to the mouth and throat is an inflammation of the mucus membranes that line the mouth and throat. This condition is called mucositis and it can make it difficult to eat and swallow. Try these ideas for managing a sore mouth or throat: Try to focus on foods naturally low in calories and high in fiber to help you feel full, such as vegetables, fruits, whole grains, and beans. Include small amounts of higher calorie foods that you enjoy most, and be sure to savor them for the most satisfaction. Pay attention to portion sizes and fill most of your plate with lower calorie plant foods. Avoid alcohol, citrus, caffeine, vinegar, spicy foods, and acidic foods (like tomatoes).

Well-informed policy and decision makers can advocate for changes in and funding of services and additional research in these areas. Key strategies for addressing this need include the following: Identify potential policy and decision makers and establish mechanisms to educate them on survivorship issues. Cancer survivors are faced with extremely difficult medical decisions at each stage of living with, through, and beyond cancer. Patient navigation systems attempt to provide a mechanism to enhance the delivery of optimum care. However, this information may be inconsistent in the message content, culturally inappropriate, and/or difficult to access. A system to evaluate the validity of available cancer survivorship information is needed that can be linked to other, reliable information sources. Key strategies for addressing this need include the following: Develop a standardized system to assess the adequacy of available survivorship information. Educate health care providers about cancer survivorship issues from diagnosis through long-term treatment effects and end-of-life care. Health care providers include all clinical, community, and public health professionals who potentially affect the health and well-being of people living with cancer. Although the specific message will vary for different types of providers, all should understand the impact a cancer diagnosis has on quality of life, the common myths and misperceptions about cancer and accurate information to dispel them, prevention strategies for secondary illnesses, appropriate management strategies, referral sources. Key strategies for addressing this need among providers include the following: Establish educational forums on survivorship in partnership with professional organizations. Communication, Education, and Training 39 Section V Summary: Communication, Education, and Training 1. Develop strategies to educate the public that cancer is a chronic disease people can and do survive. Develop, test, maintain, and promote patient navigation systems for people living with cancer. Goals this section describes prioritized needs and recommended strategies for programs, policies, and infrastructure at national, state, and community levels to advance cancer survivorship within public health settings. Goals include the following: Develop a continuum of health programs and services that addresses both cancer treatment needs and primary, secondary, and tertiary prevention of additional health concerns for cancer survivors. Medical, psychosocial, legal, and financial issues could be addressed by programs that are comprehensive in scope and encompass care for each stage of cancer survivorship. These policies may be implemented at the national, state, organizational, and community levels in an effort to advance public health. Infrastructure Infrastructure is comprised of the basic resources and facilities in place to address survivorship and includes components of the health care and public health systems, such as state and local health departments, and the services and programs they provide. Prioritized needs for these components and suggested strategies for addressing them are presented in the following section. Prioritized Needs and Suggested Strategies It is through programs, policies, and infrastructure that public health can effect change in terms of the delivery of services for cancer survivors. Survivorship initiatives could be embedded in all services related to the continuum of care, including cancer prevention, screening and early detection, diagnosis and treatment, rehabilitation, and palliative and end-of-life care. These programs may be offered through a variety of sources, such as comprehensive cancer centers, advocacy organizations, or community-based organizations (Tesauro et al. Policies may be implemented at the national, state, and community levels to create an environment supportive of advancing cancer survivorship in the realm of public health. This document serves as an example of how an advocacy organization can advance policy in the realm of cancer survivorship. Exploring ways that public health policy can be developed to address the needs of cancer survivors is an important next step in action planning. To ensure that cancer survivorship innovations reach the people who need them most, states, territories, and tribal organizations need to build and maintain appropriate infrastructure. Sufficient scientific and programmatic infrastructure will enable health agencies to build the necessary coalitions and partnerships to translate research into public health programs, practices, and services for cancer survivors. Develop, test, maintain, and promote patient navigation or case management programs that facilitate optimum care. Patient navigation is a tool that can be used to ensure that survivors understand their care and their process of care and enhance the delivery of optimum care. In these programs, health professionals or highly trained patient liaison representatives coordinate health care 44 A National Action Plan for Cancer Survivorship: Advancing Public Health Strategies for patients and assist them in navigating the health care system. Within the realm of cancer survivorship, there is much to learn about the best practices of programs that address needs for people living with, through, and beyond cancer.

However, some protein products, particularly some animal-based sources, are high in saturated fat, so non-fat, low-fat, or lean choices should be selected. Fat intake should emphasize monounsaturated and polyunsaturated fats, such as those found in seafood, nuts, seeds, and oils. Overall, See Chapter 5 for additional discussion of eating as long as foods and patterns that meet nutrient beverages consumed needs within calorie limits. Individuals should consider the calories from all foods and beverages they consume, regardless of when and where they eat or drink. Substituting active pursuits for sedentary time can help people manage their weight and provides other health benefits. The 2008 Physical Activity Guidelines for Americans provides guidance to help Americans improve their health, including weight management, through appropriate physical activity (see Table 2-5). The amount of physical activity necessary to successfully maintain a healthy body weight depends on calorie intake and varies considerably among adults, including older adults. To achieve and maintain a healthy body weight, adults should do the equivalent40 of 150 minutes of moderate-intensity aerobic activity each week. If necessary, adults should increase their weekly minutes of aerobic physical activity gradually over time and decrease calorie intake to a point where they can achieve calorie balance and a healthy weight. Some adults will need a higher level of physical activity than others to achieve and maintain a healthy body weight. Some may need more than the equivalent of 300 minutes per week of moderate-intensity activity. For children and adolescents ages 6 years and older, 60 minutes or more of physical activity per day is recommended. Although the Physical Activity Guidelines do not include a specific quantitative recommendation for children ages 2 to 5 years, young children should play actively several times each day. Children and adolescents are often active in short bursts of time rather than for sustained periods of time, and these short bursts can add up to meet physical activity needs. Physical activities for children and adolescents of all ages should be developmentally appropriate and enjoyable, and should offer variety. Department of Health and Human Services released a comprehensive set of physical activity recommendations for Americans ages 6 years and older. Weight management along with health outcomes, including premature (early) death, diseases (such as coronary heart disease, type 2 diabetes, and osteoporosis), and risk factors for disease (such as high blood pressure and high blood cholesterol) were among the outcomes considered in developing the 2008 Physical Activity Guidelines for Americans. Strong evidence supports that regular participation in physical activity also helps people maintain a healthy weight and prevent excess weight gain. Further, physical activity, particularly when combined with reduced calorie intake, may aid weight loss and maintenance of weight loss. This means increasing awareness of what, when, why, and how much they eat, deliberately making better choices regarding what and how much they consume, and seeking ways to be more physically active. Several behaviors and practices have been shown to help people manage their food and beverage intake and calorie expenditure and ultimately manage body 39. One minute of vigorous-intensity physical activity counts as two minutes of moderate-intensity physical activity toward meeting the recommendations. Muscle-strengthening activity: Physical activity, including exercise, that increases skeletal muscle strength, power, endurance, and mass. It includes strength training, resistance training, and muscular strength and endurance exercises. Bone-strengthening activity: Physical activity that produces an impact or tension force on bones, which promotes bone growth and strength. The behaviors with the strongest evidence related to body weight include: Focus on the total number of calories consumed. Consuming an eating pattern low in calorie density may help to reduce calorie intake and improve body weight outcomes and overall health. Monitoring intake has been shown to help individuals become more aware of what and how much they eat and drink. The Nutrition Facts label found on food packaging provides calorie information for each serving of food or beverage and can assist consumers in monitoring their intake. When possible, order a small-sized option, share a meal, or take home part of the meal. Review the calorie content of foods and beverages offered and choose lower-calorie options.

The rule describes the requirements and controls for electronic systems that are used to fulfill records requirements set forth in agency regulations (often called "predicate rules") and for any electronic records submitted to the agency. The current guidance document is Guidance for Industry: Part 11, Electronic Records; Electronic Signatures ­ Scope and Application, 25 dated August 2003. Resource Considerations Costs for registries can be highly variable, depending on the overall goals. Costs are also associated with the total number of sites, the total number of patients, and the geographical reach of the registry program. Table 11­2 provides a list of some of the activities of the registry coordinating center as an example. Not all registries will require or can afford all of the functions, options, or quality assurance techniques described in this chapter. Registry planners must evaluate benefit versus available resources to determine the most appropriate approach to achieve their goals. Data activities performed during registry coordination Data Management Defines all in-process data quality control steps, procedures, and metrics. Data Collection and Quality Assurance Case Examples for Chapter 11 Case Example 24. Developing a performancelinked access system Description the Teva Clozapine Patient Registry is one of several national patient registries for patients taking clozapine. The goal is to prevent clozapine rechallenge in patients at risk for developing clozapine- induced agranulocytosis by monitoring lab data for signs of leukopenia or granulocytopenia. Proposed Solution the risk of developing agranulocytosis is mitigated by regular hematological monitoring and is a condition of access to the drug, also known as the "no-blood/no drug" requirement. The core components of the system are a call center, a Web site, and a reminder system. Patients must be enrolled prior to receiving clozapine, and they must be assigned to a dispensing pharmacy and treating physician. If there are no low counts, the patient can be monitored every 2 weeks for an additional 6 months. The registry provides reminders if laboratory data are not submitted according to the schedule. However, clozapine is known to be associated with a risk of developing agranulocytosis, a potentially life-threatening condition. Developing a performancelinked access system (continued) Proposed Solution (continued) identified, registry staff inform the health care providers to make sure that they are aware of the event and appropriate action is taken. Results Results indicate that the registry is achieving its goal of reducing the risk of agranulocytosis associated with the use of clozapine by serving as an early warning system. By linking access to clozapine to a strict schedule of laboratory data submissions, the sponsor can ensure that only eligible patients are taking the drug. The sponsor is also able to detect low counts, prevent inappropriate rechallenge (or re-exposure) in at-risk patients, and monitor the patient population for any adverse events. This system provides the sponsor with data on the frequency and severity of adverse events while ensuring that only the proper patient population receives the drug. A secure, fully functional Web site allows health care professionals to manage their patients electronically. A reminder system permits rapid notification to providers to ensure that appropriate actions are taken when low counts are detected or if laboratory reports are not submitted in a timely manner. These systems can also help sponsors monitor the patient population to learn more about adherence, compliance, and the frequency of adverse events. Incidence of leukopenia and agranulocytosis with the use of clozapine: Evidence from the Teva Clozapine Patient Registry. The purpose of the registry is to collect and exchange information to support continuous improvements in the quality, safety, effectiveness, and cost of caring for patients with vascular disease. It was determined that an audit of participating sites, focusing on included versus eligible patients, could reasonably address whether this was a significant issue. However, the group needed to overcome two logistical challenges: (1) the audit had to review thousands of eligible patients at participating hospitals in a timely, cost-effective manner; and (2) the audit could not overburden the hospitals, as they participate in the study voluntarily. Proposed Solution the registry team developed a plan to conduct the audit using electronic claims data files from the hospitals.

Assess that resources for cancer services and insurance coverage are consistent with current recommendation. Assist patients and families in navigating the health care system following cancer treatment. Recognize the importance of survivorship in a long-term cancer care plan at the conclusion of active treatment. Provide support for cancer survivors and their families and caregivers as they cope with daily living, including lifestyle, employment, school, sexual relationships, fertility issues, and personal intimacy. Describe the methods used to diagnosis cancer pain throughout the progression of the disease. Describe the characteristics used to assess cancer pain: frequency, intensity, and site. Describe the contribution of each professional perspective in the development of cancer care plan. Refer patients to an oncology social worker for financial guidance and resource navigation. Incorporate Psychosocial Communication Strategies in Conveying Cancer Information 1. Incorporate Cross-Cultural Communication Strategies in Conveying Cancer Information 1. Communicate cancer care information that is sensitive to religious and spiritual beliefs and practices. Elaboration is required for each of these content areas, specifying behavioral descriptors for the underlying knowledge, skills, and attitudes required for (1) different sectors of the workforce. Such sophistication in competency identification and assessment is required to move the field beyond the common and limited practice of simply listing generic competencies with no specificity or behavioral anchors (Hoge et al. Competency-based approaches offer a flexible foundation for staff development and assessment. Traditional approaches, in which qualifications or abilities are inferred from degrees, certification, licensure, discipline, or job description, lack specificity regarding skills and are of little utility when assessing skills that are shared by multiple segments of the workforce. Conceptualizing case management as a function or competency, defined by clear behavioral descriptors and several levels of expertise, would provide for greater utility and flexibility in providing training in and assessing workforce capacities. Faculty Needs Identified educational competencies are necessary but insufficient for the development of student/trainee knowledge and skills. Sufficient numbers of faculty who themselves possess the requisite attitudes, knowledge, and skills are required to teach the competencies. Faculty development programs are widely used to help train a critical mass of faculty in areas identified as deficient, such as education about substance use (Haack and Adger, 2002). Some professions, such as nursing, additionally suffer from an inadequate supply of faculty generally. Faculty development programs that attend to both numbers and expertise are needed to ensure the application of the competencies across health professions schools. Effectie Teaching Practices Competency identification and curriculum development provide a foundation for training and education. However, they must be combined with effective teaching practices to achieve the desired learning outcomes (Stuart et al. A substantial evidence base exists in medicine regarding effective teaching and skill development approaches (Davis et al. The principal finding of research in this area is that didactic or noninteractive, single-session lectures and workshops constitute the most common training approaches in continuing education and much of preservice education, but have virtually no effect in changing the practice behaviors of trainees (Mazmanian and Davis, 2002; Bloom, 2005). Davis and colleagues (1999) argue that the evidence on this issue is so strong that continuing Copyright National Academy of Sciences. Oxman and colleagues (1995) conclude there is no single magic bullet for achieving skill development and change in practice behaviors among learners. Combining multiple teaching strategies, each proven to have small effects on practice behavior, represents an evidenced-based approach to teaching.