CSO exam- My experience taking the test the 1st time

My experience taking the CSO exam the 1st time I studied for months before taking the September 2008, CSO exam. I felt confident that I would ace the exam. I memorized a lot of information from the Candidate Handbook. I created flashcards from the Oncology Nutrition Test Specifications; spent countless hours preparing for the big day. I assumed that my years of experience and months of studying would result in total confidence on exam day. I had worked as an inpatient oncology dietitian at a large 500-bed hospital since 2004 and transitioned to the outpatient cancer center position in August 2008. Much to my surprise the CSO exam was challenging. I left the testing site sick to my stomach. I thought there was a good chance I would need to take the CSO exam again in March. When I returned to work my supervisors, co-workers and a medical oncologist asked me if I passed. I honestly said, "I don't know. The exam was very difficult." I felt embarrassed for 6 weeks and waited on pins and needles to discover that I passed! UPDATE: It's been 11 years since I took the CSO exam the 1st time. I recertified in 2013 & 2018. High stakes tests are always stressful- even after decades of practice experience. But have faith, you can do it!

Nausea and vomiting related to cancer treatment

The guidelines for managing nausea & vomiting are different for anticipatory, acute, or delayed nausea & vomiting.

Anticipatory nausea and vomiting: occurs prior to the beginning of a new cycle of chemotherapy. This occurs after the patient has experienced N&V from an earlier chemotherapy treatment.

Acute nausea and vomiting: occurs during the first 24-hours after chemotherapy.

Delayed nausea and vomiting: occurs more than 24 hours after chemotherapy. Patients at highest risk for delayed N&V include those receiving cyclophosphamide, cisplatin, doxorubicin and ifosfamide.
(National Cancer Institute, http://www.cancer.gov/)

Chemotherapy agents are categorized according to their potential to induce nausea & vomiting.
High risk >90%
Moderate risk 30-90%
Low risk 10-30%
Minimal risk <10%

Single IV Agents
Highly emetogenic:
Cisplatin
Mechlorethamine
Cyclophosphamide >1500mg/m2
Carmustine
Dacarbazine

Moderate emetogenic:
Oxaliplatin
Cytarabine >1gm/m2
Carboplatin
Ifosfamide
Cyclophosphamide <1500mg/m2
Doxorubicin

Daunorubicin

Epirubicin

Idarubicin

Irinotecan

Low emetogenic:
Paclitaxel
Docetaxel
Topotecan
Etoposide
Methotrexate
Mitomycin
Gemcitabine
Cytarabine

Minimal emetogenic:
Bleomycin
Busulfan
Fludarabine
Vinblastine
Vincristine
Vinorelbine
Bevacizumab

Guideline for Antiemetic Use:
An antiemetic regimen administered before chemotherapy is recommended to prevent acute nausea and vomiting. This three-drug combination is recommended by ASCO (American Society of Clinical Oncology) for highly emetogenic chemotherapy medications:
1. Serotonin 5-HT3 receptor antagonist (Ondansetron, dolasetron, granisetron, palonosetron)
2. Dexamethasone (corticosteroid)
3. Aprepitant (NK1 receptor antagonist)
(©MASCC 2007, Multinational Association of Supportive Care in Cancer)

5-HT3 antagonists are most effective in the prevention and treatment of chemotherapy-induced nausea and vomiting (CINV), especially that caused by highly emetogenic drugs such as cisplatin; when used for this purpose, they may be given alone or, more frequently, with glucocorticoid, usually dexamethasone. They are usually given intravenously, shortly before administration of the chemotherapeutic agent. The concomitant administration of a NK1 receptor antagonist, such as aprepitant, increases the efficacy of 5-HT3 antagonists in preventing both acute and delayed CINV.
The 5-HT3 antagonists are also indicated in the prevention and treatment of radiation-induced nausea and vomiting (RINV) and post-op nausea and vomiting (PONV).
From Wikipedia, the free encyclopedia

Suggestions for managing delayed nausea & vomiting:

The combination of dexamethasone and aprepitant

Suggestions for managing anticipatory nausea & vomiting:

Physchological techniques and/or the use of benzodiazepines such as lorzepam (Ativan®)




Nutrition Tips for Managing Nausea & Vomiting:
*Eat small, frequent meals and snacks
*Eat toast, crackers, dry cereal, bread sticks, pretzels
*Try yogurt, sherbet, rice, noodles, baked chicken
*Serve foods cold or at room temperature
*Avoid hot, spicy foods
*Avoid fatty, greasy and fried foods- potato chips, french fries, fried meat and sausage
*Avoid sweet, fatty foods such as candy, cookies or cake
*Avoid caffeine and alcohol
*Suck on hard candies, peppermints or lemon drops
*Slowly drink or sip liquids throughout the day including sports drinks, ginger ale, apple juice and flat pop
*Try Ensure® Enlive! (apple or mixed berry) supplement or Nestle Nutritional juice beverage

Nutrition interventions for stomatitis/mucositis

Stomatitis: Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, throat, and roof or floor of the mouth.

Mucositis is the painful inflammation & ulceration of the mucous membranes lining the digestive tract, usually as an adverse effect of chemotherapy and radiation treatment for cancer.

Wikipedia, the free encyclopedia

Not everyone undergoing cancer treatment develops mouth sores.
Approximately 400,000 cancer patients develop mouth sores every year in the United States.
Sores are likely to appear within 10 days of starting some cancer treatments.
The ulcers and pain usually disappear within 3 weeks after treatment is completed.
(©CANCERcare 2005, www.cancercare.org)

Some forms of chemotherapy cause damage to the gastrointestinal mucosa, including Methotrexate, Melphalan, Irinotecan & 5-fluorouracil (5-FU).

Radiation to the head and neck or to the pelvis or abdomen causes mucositis in greater than 50% of the patients.

Mucositis can affect the entire alimentary track from the mouth to the rectum.

Stomatitis: mouth inflammation

Esophagitis: esophageal inflammation

Gastritis: stomach inflammation

Enteritis: Intestinal inflammation, especially the small intestine

Mucositis is a common side effect of high-dose chemotherapy or total body irradiation (TBI) given prior to hematopoietic stem cell transplantation (HSCT). An estimated 75-85% of HSCT recipients experience mucositis, of which stomatitis is the most common and debilitating side effect.

Mucositis Management:
* Avoid carbonated beverages, caffeine, alcohol and tobacco
* Avoid rough or coarse foods: raw fruits & vegetables, pretzels, popcorn, chips, crackers & nuts
* Avoid spicy or acidic foods: tomatoes, oranges, grapefruit, lemon, chili, tacos, pickles, vinegar
* Supplement diet with health shakes and milkshakes
* Trial soft, moistened foods or pureed foods
* Serve foods cold or at room temperature
* Gargle regularly with a solution made of 1 quart of plain water, ½ tsp. table salt, ½ tsp. baking soda
* Drink water and other fluids frequently throughout the day. Chew sugarless gum or suck on sugarless hard candy to moisten the mouth. Use artificial saliva frequently
* Suck on ice chips or Popsicles
* Avoid mouthwash that contains alcohol
* Over the counter anesthetics such as Xylocaine, Anbesol or Orajel may soothe the pain
* Gelclair provides pain relief by adhering to the mucosal surface of the mouth & soothing oral lesions. It forms a protective barrier in the mouth. Available by prescription only
* Caphosol lubricates & cleanses the mouth similar to human saliva
* Palifermin (Kepivance) speeds the healing of mucositis and stops sores from forming in the lining of the mouth and throat. It is used in patients that received high-dose chemotherapy followed by HSCT.

Copyright 2007-2008. Sharlene Bidini, RD. All rights reserved.