The cancer patient who develops malglycemia (another word for hyperglycemia experienced by nondiabetic patients)—either due to cancer itself or to drugs patients take for their cancer—is somewhat of a “hot potato.” If the oncologist refers the patient to the primary care physician (PCP), the PCP often sends the patient back to the oncologist. At least that has been the experience of Diane De Vos-Schmidt, RN, MSN, OCN, a nurse at PCR Oncology in Pismo Beach, California.
De Vos-Schmidt was aware that some patients in her practice were developing blood glucose levels in the high 300s, but no one was treating this. “The sequelae from this can be very bad—even death. Malglycemia makes cancer cells grow faster, which is bad for most solid tumors, and insulin-like growth factor interferes with treatment. Patients with very high blood sugar have to fight a double whammy—cancer and the metabolic syndrome,” she noted.
When her friend and colleague developed malglycemia, De Vos-Schmidt decided to take action. Jacqueline Loughran-Hertzog, a fellow nurse in De Vos-Schmidt’s practice, had a symptomatic neuroendocrine tumor of the pancreas that caused diabetes.
“She now had two problems—cancer and diabetes. On routine testing, her blood sugar was in the range of 300 to 400 [mg/dL], and she became the ‘hot potato.’ Together we approached our boss, David Palchak, MD, and he agreed to lower her [blood sugar level]. We gave her insulin 3 times a day before meals and consulted with a diabetes nurse educator,” De Vos Schmidt explained. Her colleague’s malglycemia resolved, and the cancer treatment put her in remission.
This experience led to a “home-grown” research project, which was the subject of a poster presentation at the 38th Annual Congress of the Oncology Nursing Society. De Vos-Schmidt and a diabetes educator, Kris Dilworth, RN, MS, FNP, CDE, developed a treatment algorithm for patients taking corticosteroids (a known risk factor for malglycemia). Their study included 26 patients who were screened over a 3-month period after their first chemotherapy treatment. Patients with blood glucose readings in the range of 140 to 199 mg/dL received a glucose meter, training, and nutrition education limiting carbohydrate intake. Those with higher blood glucose readings were treated similarly and, in addition, had insulin initiated according to an insulin scale developed for this project. Of the 26 patients, 47% had high glucose levels that required intervention.
“All patients were kept euglycemic during the remainder of their treatment, and patient compliance was 100%,” she said. “But acceptance by the nursing staff was not universal.”
There is currently no evidence-based solution for malglycemia that occurs during cancer treatment, she continued. De Vos-Schmidt hopes that this pilot study will generate further research. She noted that these patients were asymptomatic, and their extremely high blood sugar levels would not have been discovered unless they had been screened.
“Patients walk around with this dangerous asymptomatic condition that fuels their cancers. It is amenable to treatment if recognized, and the nurse does not need the doctor’s orders for a finger stick. This is easily done when patients on steroids come in on day 2 during treatment for growth factor support,” she noted.
De Vos-Schmidt D, Dilworth K. Management of steroid induced malglycemia during cancer treatment. Presented at: 38th Annual Congress of the Oncology Nursing Society; April 25, 2013; Washington, DC. Poster.