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![Introduction
The 35th Annual Oncology Nursing Society (ONS) Congress was held May 13-16, 2010, in San
Diego, California. This Conference Report reviews current topics of interest to oncology nurses,
including both treatment and supportive care. Tracy K. Gosselin, RN, MSN, AOCN, and Sandra
E. Kurtin, RN, MS, AOCN, ANP-C, discuss the relevance to clinical practice of some of the most
important topics discussed at the meeting.
Topics include the use of molecular and genetic testing to guide treatment for patients with
colorectal cancer, risk evaluation and management strategies, safety standards for the
administration of chemotherapy agents, the benefits and adverse effects of novel agents,
management of chemotherapy-induced and radiotherapy-induced toxicities, and management
of neutropenia. A key take-home message is that oncology nurses need to fully understand a
patient’s treatment regimen, understand patients as individuals, assess comorbidities, and
determine how likely a patient is to respond to a given therapy for his or her tumor type.
Colorectal Cancer: Individualized Care
Tracy K. Gosselin, RN, MSN, AOCN: Colorectal cancer is the third most common cancer
among men and women in the United States. It is estimated that in 2010, more than 142,000
new cases of colorectal cancer will be diagnosed, leading to more than 51,000 deaths.[1] Nurses
managing patients with colorectal cancer have multiple patient-specific factors to contend with
that can influence a patient’s experience and outcomes.
Common modifiable and nonmodifiable risk factors in patients with colorectal cancer include
exercise level, diet, and body mass index. Measures to reduce these risks, as well as
screening, identification of prognostic factors, understanding the development of colorectal
cancer (eg, Vogelstein’s pathway[2]) and managing toxicities, are key to optimal patient care.
Testing for predictive or prognostic biomarkers, including microsatellite instability,[3] genomic
aberrations, and the presence or absence of proteins, is becoming an important part of
individualizing care in the setting of colorectal cancer. Different testing criteria are used
depending on personal and family histories. Perhaps the most important test is to determine
whether KRAS is mutated—approximately 40% of colorectal cancer patients have a KRAS
mutation linked to increased risk of nodal metastasis and potentially more aggressive tumor
behavior.[4-6]
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Determining whether a patient has wild-type or
mutant KRAS also dictates whether or not anti–epidermal growth factor receptor (EGFR)
monoclonal antibodies are used in treatment, as mutations in codons 12 and 13 in exon 2 of
KRAS confer resistance to treatment with EGFR inhibitors.[7-9] The National Comprehensive
Cancer Network (NCCN) now recommends that testing for KRAS mutations be conducted
before treatment with cetuximab or panitumumab, the 2 anti-EGFR antibodies used today in the
treatment of colorectal cancer.[10] The American Society of Clinical Oncology (ASCO) issued a
provisional opinion recommending that patients with metastatic colorectal cancer and KRAS
mutations in codon 12 or 13 not receive anti-EGFR antibody therapy.[11] Testing for KRAS
mutations can spare affected patients the cost and toxicity of an ineffective treatment.
Tracy K. Gosselin, RN, MSN, AOCN: Other tests used to individualize treatment of patients
with colorectal cancer include immunohistochemical staining to identify 4 mismatch repair
(MMR) proteins with prognostic significance; if 1 or more are absent in tumor tissue, there is
cause for concern. In hereditary nonpolyposis colorectal cancer, the most common form of
inherited colorectal cancer, detection of the causal alteration of the MMR gene involved is
essential for proper management of the disease. Detection of this alteration allows the
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![identification of relatives who are at high risk for colorectal or endometrial cancer and who
therefore require appropriate screening. Determining whether family members have the MMR
alteration can also avert useless surveillance in noncarriers. Mutational studies based on
conventional screening methods have indicated that point mutations of the MMR genes MSH2,
MLH1, or MSH6 can be detected in approximately 55% of families with hereditary nonpolyposis
colorectal cancer.[12,13]
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: These changes in patient assessment have
affected the colorectal cancer population that I work with. Colorectal cancer as a diagnosis is a
broad umbrella, and some areas under that umbrella are still being identified. This includes risk
factors—young patients in their 20s are presenting with metastatic disease, so understanding
why that is happening, including what is going on at the molecular level within the tumors, is
critical. One reason this is important is that certain molecular abnormalities can predispose
patients to significant toxicities. For example, microsatellite instability is used to guide whether a
patient with low-grade disease should be treated or not.
Patients with early stage colorectal cancer (high-risk stage II) who are positive for microsatellite
instability may actually have an increased risk of recurrence when exposed to 5-fluorouracil
agents used commonly in adjuvant therapy for high-risk disease. In this setting, patients who
are homozygous for the UGT1A1*28 allele have an increased risk of developing severe
neutropenia when receiving irinotecan.[14] Molecular assays are available to identify at-risk
subgroups, although widespread use is not common. More often, patients who experience
unusual toxicity are tested for the UGT1A1*28 allele; if it is present and homozygous,
subsequent doses may be modified.
Tracy K. Gosselin, RN, MSN, AOCN: These changes in assessment of colorectal cancer
patients are reflected in the NCCN guidelines,[10] which recommend screening patients for
mutations in KRAS, BRAF, and MMR genes and for microsatellite instability.
For patients receiving chemotherapy for colon cancer, nurses should apply the National Quality
Forum quality measures,[15] which reflect the transition of medical care toward more
individualized treatment strategies. The American College of Surgeons’ Commission on Cancer
guidelines for the staging of colon cancer and the NCCN guidelines are also important for
nurses to be aware of.[10,16,17]
In the past, treatment of colorectal cancer and other malignancies was individualized based on
a pathology report, radiology films, and laboratory studies. Now, with the identification of
biomarkers such as MMR and KRAS alterations, it is increasingly important for oncology nurses
and advanced-practice nurses to understand how these novel factors relate to staging and
treatment.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Yes, nurses need to become familiar with the
pathophysiology of colorectal cancer and thereby understand why different newly diagnosed
patients may require very different approaches to therapy based on tissue analysis.
Managing Risks in Cancer Patients Using Risk Evaluation and
Mitigation Strategies
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Risk evaluation and mitigation strategies (REMS)
are used to manage known or potential serious risks with a drug or biologic therapy.[18] REMS
may be required if deemed necessary by the US Food and Drug Administration (FDA) to ensure
that the benefits of an agent outweigh the risks and may be required before or after approval.
For example, newly recognized risks, new findings concerning a known adverse drug reaction,
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![or changes in frequency or severity of risk factors may be reasons to implement postapproval
REMS programs.[19]
Tracy K. Gosselin, RN, MSN, AOCN: From a provider or prescriber standpoint, REMS can be
confusing. The 3 main categories of REMS are[18]:
• Medication guide (patient package insert)
• Communication plan for healthcare provider
• Elements to ensure safe use
The different elements of REMS include the implementation of systems, special labeling
requirements, postapproval studies, and an assessment timetable.
Nursing concerns regarding REMS include training and educational requirements, cost and time
involved, and the fact that there are different REMS requirements for each agent. Areas of
concern exist for prescribers and staff as well, related to the effect of REMS on the
multidisciplinary team. Prescribers need to be aware of emerging changes in REMS and REMS
requirements, not only in a broad sense but also for each therapeutic agent. Settings such as
infusion centers may be required to distribute educational materials to patients.
REMS also affect patients, who may have concerns about decreased access for treatment
stemming from cost, fear, and limited locations that can dispense certain drugs.[20,21] Indeed,
even before the development of REMS, there have been issues with patients gaining access to
necessary treatment. This is an interesting area of oncology nursing; in the future, the number
of therapies with REMS requirements could affect drug distribution systems as well as access
by patients.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: REMS are widely implemented, for example, in
patients receiving erythropoiesis-stimulating agents (ESAs); the 2 ESAs approved in the United
States are epoetin alfa and darbepoetin alfa. ESAs are often used to treat patients with anemia
but have been associated with increased risk of tumor growth and decreased survival in
patients with cancer, as well as risks of heart attack, heart failure, stroke, and blood clots.[22] The
Assisting Providers and Cancer Patients with Risk Information for the Safe Use of ESAs REMS
program is required for all healthcare providers prescribing or dispensing ESAs (http://www.esa-
apprise.com). Completing the training module takes approximately 15 minutes. The module
describes adverse outcomes seen with ESAs, describes appropriate use of ESAs for patients
with cancer (eg, only if hemoglobin is ≥ 10 g/dL, only in patients receiving myelosuppressive
chemotherapy, only in nonmyeloid malignancies), and sets out the requirements for healthcare
providers[23]:
• Provide patient education guides from the manufacturer every time an ESA is dispensed
• Conduct a risk/benefit discussion with the patient, including addressing patient questions
and concerns, and fill out a form showing they have done so
• Inform each patient that ESAs are associated with increased mortality, serious
cardiovascular and thromboembolic events, and increased tumor progression or
recurrence
REMS are required or recommended for more than 100 drugs in many other classes of drugs as
well, including the opioids (eg, fentanyl, morphine, oxycodone), which carry risks of misuse,
abuse, and accidental overdose. For this class of drugs, physician education is voluntary, and
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![the manufacturers provide patient education materials to be used during patient counseling
sessions. The opioid REMS are currently (2010) undergoing revision by the FDA.[24]
REMS are also required for the immunomodulatory agents thalidomide and lenalidomide owing
to historical data associating thalidomide with birth defects (teratogenicity). Although no cases
of birth defects have been reported for lenalidomide, it has been included in the REMS program
due to the similar molecular structure and mechanism of action of the drugs. Both thalidomide
and lenalidomide may be obtained only after completion of a screening and safety program.
Oncology nurses apply REMS on a daily basis as part of their ongoing management of the
potential risks of a therapy. Physicians and nursing staff must know and communicate the risks
and benefits of a given therapy. However, implementing REMS can become overwhelming due
to its complexity; in some cases, providers will decide that REMS make a therapy too difficult to
use, which can limit access to a beneficial agent.
Tracy K. Gosselin, RN, MSN, AOCN: For instance, blood transfusion rates have begun to
increase, in part due to the implementation of REMS, which result in not being able to use ESAs
as freely as with previous established safety guidelines.[25]
ONS/ASCO Chemotherapy Safety Standards
Tracy K. Gosselin, RN, MSN, AOCN: The ONS and ASCO have developed safety standards
for administration of chemotherapy agents.[26] The criteria for these standards were that they
should be applicable to diverse practice settings, understandable and clinically intuitive, realistic
to achieve, evidence based, reliable, measureable, and actionable. The 31 standards
encompass 7 domains, each with several areas specific to the different steps in chemotherapy
administration:
• Review of clinical information and selection of treatment regimen
• Treatment planning and informed consent
• Ordering of treatment
• Drug preparation
• Assessment of treatment compliance
• Administration and monitoring
• Assessment of response and toxicity monitoring
The standards set forth help nurses understand the complex process of chemotherapy
administration, including the facility type and available resources. Interestingly, the new
standards include considerations regarding oral chemotherapy agents, and may affect how
institutions manage these agents. For example, verification is required of the drug name, dose,
volume, expiration, and appearance/physical integrity. The guidelines also discuss optimal use
of a variety of different methodologies related to monitoring and assessment of treatment with
chemotherapies. For instance, during each clinical visit, staff should document changes in
patient clinical status, weight, and performance status, as well as psychosocial concerns and
need for support. Nurses also need to document and record changes in the patient’s current
medications, including over-the-counter, complementary, and alternative therapies.
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![As these standards are incorporated into ASCO’s Quality Oncology Practice Initiative,[27] it will
be important to carefully look at how they are implemented in clinical practice to mitigate risk.
This may require institutions to conduct failure mode effect analysis and process mapping to
understand their process regarding chemotherapy, and to identify the risks and the practice
gaps.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Chemotherapy safety standards need to be
applicable to the variety of settings seen in oncology practices today. The standards must allow
practitioners to maintain safety but not become so stringent that they are more suited to an
academic setting where there are many more people and more resources. Putting these
standards into practice is definitely challenging.
For example, in a small community practice where an oncology nurse may mix and administer
chemotherapeutic agents for multiple patients each day, application of the safety standards (eg,
use of specialty gloves, gown, mask) may impede efficiency and increase costs to the practice.
Although the safety of the nurse and of the patient is the primary concern, further studies are
necessary to promote practices that both provide for safety and are feasible in a wide variety of
settings.
Immunotherapy for Advanced Melanoma
Tracy K. Gosselin, RN, MSN, AOCN: A survey was presented that looked at the practice
patterns of nurses with regard to immunotherapy for advanced melanoma.[28] Nurses filled out a
16-item questionnaire covering demographics, nursing knowledge, attitudes, and practice
behaviors. The sample size was 60 nurses, 51% of whom held a master’s degree. Sixty-four
percent of respondents reported using interferon alfa-2b for the adjuvant treatment of stage III
melanoma; this finding is unsurprising given that melanoma does not have a wide
armamentarium of agents to use for treatment. Approximately 20% reported combination
chemotherapy plus interleukin (IL)-2 as the most commonly used treatment for stage IV
disease. Interestingly, 40% of respondents noted that they did not have institutional guidelines
to manage the adverse effects for immunomodulatory targeted agents. Yet, good information
regarding the management of adverse effects is available, indicating a gap in translating
evidence into practice.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: The newer targeted therapies are being refined and
are expanding into specific diagnostic groups in diseases that are outside of the typical
chemotherapeutic administration setting for many practices. A community practice may see only
1 or 2 patients with a particular disease, and it can be challenging to readily access information
regarding adverse effects of novel therapies in this situation.
Tracy K. Gosselin, RN, MSN, AOCN: This study provides an interesting look at how nurses,
especially advanced-practice nurses, treat melanoma. Unfortunately, the incidence of
melanoma is rising—by nearly 3% per year since 1980.[29,30]
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Yes, which means more nurses need education
regarding the treatment of melanoma, including information regarding newer drugs that are
becoming more widely available. Many novel therapeutic strategies are under investigation for
the treatment of melanoma, including the following:
• Peptide vaccination plus IL-2: phase III data regarding the gp100:201-217 vaccine
showed significant improvements in response rates and progression-free survival (PFS)
vs IL-2 alone[31]
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![• BRAF kinase inhibition: phase I data regarding a selective inhibitor of the oncogenic
V600E mutant BRAF kinase, PLX4032, suggest the potential for improved responses
and tumor progression[32]
• Angiogenesis inhibition: the combinations of dacarbazine and bevacizumab,[33] and
carboplatin/paclitaxel and bevacizumab,[34] as well as the soluble vascular endothelial
growth factor receptor aflibercept[35] have shown promising clinical activity
Personalized Treatment in Liver Cancer
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Liver cancer is one of the most common cancers
throughout the world, with an overall 5-year survival of approximately 2%.[36] In the United
States, more than 24,000 new cases of liver cancer (including intrahepatic bile duct cancer) are
expected to be diagnosed in 2010, with nearly 19,000 deaths.[29] The risk factors for liver cancer
include cirrhosis (eg, from alcohol abuse, autoimmune disease, or hepatitis B or C), diabetes,
and obesity. Inherited liver-related diseases include hemochromatosis, Wilson’s disease, and
biliary atresia.[36]
Once diagnosed, liver cancers are staged according to the Child-Pugh classification,[37] which is
based on the severity of chronic liver disease, typically cirrhosis, according to the degree of
ascites, plasma concentrations of bilirubin and albumin, prothrombin time, and the degree of
hepatic encephalopathy. An online calculator of Child-Pugh score can be found at
http://depts.washington.edu/uwhep/calculations/childspugh.htm. Patients with liver cancer are
also staged according to the tumor-node-metastasis staging system, in which stage I-II is
confined to the liver, stage IIA-C is near the liver and includes lymph nodes, and stage IV
represents metastasis beyond the liver.
Historically, treatment options have been very limited and primarily relied on surgical resection.
As a result, many patients are treated by hepatologists or liver surgeons rather than medical
oncologists or oncology nurses.
Tracy K. Gosselin, RN, MSN, AOCN: Also, if patients with liver cancer are not staying in a
surgical oncology unit after the procedure, they may not be seen by medical oncologists or
oncology nurses.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Modern treatment options for patients with liver
cancer include not only surgery, but also embolization, ablation, radiation, targeted therapies,
chemotherapy, and hepatic arterial infusion. However, to date, the sole curative treatments are
surgical resection and transplantation.[38] These are not options for the majority of patients.
Therefore, the use of liver-directed therapies has allowed many of these patients to live far
beyond their previously estimated life expectancy.
Molecularly targeted agents are now used as adjuvant therapy to treat liver cancer. For
example, the tyrosine kinase inhibitor sorafenib has been approved for the treatment of
hepatocellular carcinoma. Sorafenib binds multiple targets, including components of the
Raf/MEK/ERK pathway, which has been implicated in hepatic tumorigenesis.[39]
Mammalian target of rapamycin (mTOR) inhibitors are another promising class of targeted
therapies for the treatment of hepatic disease.[40] The mTOR protein allows progression from the
G1 to S phases and is a central regulator of cell growth and proliferation,[41] and the
PI3K/Akt/mTOR pathway is implicated in the pathogenesis of hepatocellular carcinoma.[42,43]
Clinically available mTOR inhibitors used for the treatment of liver cancer include sirolimus,
temsirolimus, and everolimus.[44]
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![Tracy K. Gosselin, RN, MSN, AOCN: With regard to embolization, nurses need to be aware
that the different types of agents (radiotherapy or chemotherapy, including microspheres) have
different safety criteria related to safe handling and administration. Embolic agents used in liver
cancer include bland materials such as gelfoam and starch microspheres, chemotherapies (eg,
cisplatin, mitomycin), radiopharmaceuticals (eg, Y90 microspheres), and alcohol. Embolic agents
are typically administered through the hepatic artery, but portal vein embolization is also used to
create hypertrophy in the nondiseased liver, thereby increasing potential liver function.[45]
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: In liver cancer, as in other malignancies, an
interdisciplinary approach to care is increasingly called for. For any given patient with a cancer
diagnosis, a multitude of specialties may be involved along with the support staff, nurses, and
other practitioners who interact with the patient. For instance, liver-directed therapies for
hepatocellular carcinoma are now being used in other diseases that metastasize to the liver,
such as colorectal cancer, to offer more strategies for treatment. Similarly, treatment with mTOR
inhibitors and multitargeted tyrosine kinase inhibitors was initially used only in renal cell
carcinoma but is now expanding into other diagnostic groups, including hepatocellular
carcinoma and some hematologic malignancies. The toxicity profiles for these agents (eg, hand-
foot syndrome, hyperkeratosis, hypertension, fatigue, and cramping) present a challenge to
oncology nurses.
As advances in understanding of these diseases are made and interdisciplinary strategies for
treatment are expanded, nurses are more likely to encounter therapies originally developed for
patients not commonly seen in the oncology nursing arena. Therefore, nurses need to remain
educated regarding evolving interdisciplinary cancer care to become more comfortable with the
complex concepts and processes. Personalized medicine is the way of the future.
Progress in Ovarian Cancer
Tracy K. Gosselin, RN, MSN, AOCN: In 2010, more than 21,000 women are expected to be
diagnosed with ovarian cancer, with more than 13,000 deaths, making it the fifth leading cause
of cancer-related death among women.[29] Many advancements in ovarian cancer treatment
have been made in recent years including improved surgical staging, understanding the
importance of cytoreductive surgery, molecular profiling, and the use of first-line chemotherapy,
especially combination therapy, for late-stage disease. It can be difficult to determine optimal
treatment for patients with chronic disease, as it is unclear whether they should receive surgery
or a platinum-free interval. If they have platinum-resistant disease, subsequent treatment
options are limited.
There are only a few agents with efficacy in ovarian cancer, and much research is under way
seeking to change this. Anastasia and colleagues[46] summarized clinical trials that have
provided progress in first-line therapies, including a phase II study of the poly(ADP-ribose)
polymerase (PARP) inhibitor olaparib; PARP repairs DNA damage in cancer cells.[47] In this
study, 57 patients with BRCA-deficient advanced ovarian cancer were randomized to olaparib at
either 400 mg or 100 mg twice daily. Interim results showed that the overall response rate was
substantially higher in the higher-dose group (33%) than in the lower-dose group (13%). The
clinical benefit rate (overall response rate and/or confirmed ≥ 50% decline in CA-125) was 58%
vs 17%, respectively. It will be a very positive advance in this setting if these positive phase II
data are confirmed in larger, randomized studies of olaparib.
The anti–vascular endothelial growth factor antibody bevacizumab, which has shown efficacy in
many other tumor types, is now being investigated for the treatment of ovarian cancer. Several
phase II studies have shown response rates to bevacizumab of 16% to 24%, with stable
disease being achieved by more than 50% of patients in each trial.[48-50] In these studies, 6-
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![month PFS ranged from 28% to 56%, and median overall survival was approximately 11-17
months. Nurses will need to be aware of the unique toxicities of this agent, including
gastrointestinal perforation, arterial thromboembolic events, grade 3 hypertension, deep vein
thrombosis/pulmonary embolism, bleeding, and wound-healing complications.
Another promising novel agent being investigated in ovarian cancer is trabectedin, which
interferes with nucleotide excision repair processes and thereby induces lethal double-strand
DNA breaks and blocks the cell cycle in the G2 phase. Results from the large OVA-301 phase
III study[51] recently showed that the addition of trabectedin to pegylated liposomal doxorubicin
(PLD) as second-line therapy significantly improved response rates in patients with ovarian
cancer from 19% to 28% (P = .008). The primary endpoint, median PFS, was 7.3 months with
trabectedin/PLD vs 5.8 months with PLD alone (P = .0190). Among patients with a platinum-free
interval of 6-12 months (ie, partially platinum sensitive), PFS, overall survival, and overall
response rate were all improved with the addition of trabectedin.[52] This combination has been
approved in Europe and is under review by the FDA in the United States. The most common
adverse reactions to trabectedin include neutropenia, nausea, vomiting, increases in aspartate
aminotransferase/alanine transaminase, anemia, fatigue, thrombocytopenia, anorexia, and
diarrhea.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: The treatment of ovarian cancer is becoming more
complex, requiring familiarity with techniques for alternative routes of treatment (eg,
intraperitoneal) as well as the potential toxicities associated with each route. For example, it is
important to take into account the different mechanisms of action of individual drugs, whether
therapies are complementary or more effective in combination, and the potential for enhanced
toxicity with this approach. Preserving future treatment options by vigilant monitoring of common
toxicities and application of prevention strategies will allow each patient the best opportunity to
receive all available therapies. The steady emergence of novel agents requires that nurses stay
current with new thinking in this difficult disease.
Tracy K. Gosselin, RN, MSN, AOCN: In ovarian (and other) cancers, the personalized
oncology continuum involving genomics, proteomics, gene-expression profiling, and
chemosensitivity testing is likely to continue driving future advances. Those advances are
dependent on clinical trials, however, and only approximately 3% of adult cancer patients are
enrolled in clinical trials.[53] There are substantial barriers to clinical trial participation, including
how patients access care, provider and patient awareness of trials, and patient preference.[54]
Chemotherapy in the Perioperative Setting
Tracy K. Gosselin, RN, MSN, AOCN: The concerns regarding use of chemotherapy in the
perioperative setting are environmental contamination, safety of staff, and protective measures.
Oncology nurses need to be familiar with the previously discussed ASCO/ONS chemotherapy
safety standards.[26] The National Institute for Occupational Safety and Health has also issued
guidelines for chemotherapy management in the perioperative setting, including safe handling,
personal protective equipment, and medical surveillance.[55] These include avoiding skin contact
with hazardous drugs, cleaning and decontamination procedures, and preparation in a
ventilated cabinet.
Typically, nurses and physicians gain knowledge about chemotherapy from their experience in
an in-patient oncology unit or an infusion suite. However, the same chemotherapy safety
standards and principles are also important in an operating room platform. Nurses need to be
aware of different ways chemotherapy is used in the perioperative setting, including peritoneal
bathing, periocular administration, isolated (regional) limb infusion/perfusion, intracranial (glial
wafer) administration, intraperitoneal catheter, and intravesicular administration.[56]
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![These factors affect patient preparation in the operating room, how long the patients might
remain in the operating room, and positioning for surgical procedures. Because patients with
cancer can have a variety of comorbid diseases, the positioning of patients with diabetes,
neuropathies, or other nerve issues needs to be carefully considered owing to the potential
postoperative complications (injury or paralysis) that could arise, in addition to the
chemotherapy safety standards. This issue is particularly important when patients might be in a
surgical position for 4-8 or even 12-24 hours.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Good point. Another significant concern regarding
chemotherapy is the potential for chemotherapy-induced neuropathy. Within the primary cancer
groups (eg, gastric, colorectal, ovarian, and peritoneal cancers, and the lymphoid
malignancies), patients often receive drugs that cause neuropathy. The most common agents
associated with chemotherapy-induced neuropathy are the platinum-containing compounds
such as oxaliplatin and cisplatin, the taxanes (paclitaxel and docetaxel), the vinca alkaloids
(vincristine and vinblastine), and the proteasome inhibitor bortezomib.
Advances in surgical technologies and the ability to conduct very fine procedures allow today’s
patients a wider range of treatment options than previously available. It will be interesting to see
how these changes affect individual comorbidities, disease outcomes, and quality of life, as well
as the ability to later treat the patient for systemic disease.
Managing Acute Toxicities During Radiation Treatment of Non-Small-
Cell Lung Cancer
Tracy K. Gosselin, RN, MSN, AOCN: Management of acute toxicities during radiation
treatment of non-small-cell lung cancer (NSCLC) is challenging for oncology nurses.[57] The
adverse effects of radiation can be debilitating and affect the patient’s well-being and quality of
life. For example, cutaneous toxicities such as erythema, blistering, and both moist and dry
desquamation can cause the patient discomfort and pain, particularly if there is skin breakdown.
Nurses can recommend appropriate skin care to patients, including avoiding sunlight and
chemical irritants, as well as the use of skin care guidelines that promote bathing and the use of
provider-recommended products.
Radiation-induced esophagitis usually develops 2-3 weeks after the patient receives external
beam radiation. Irritation to the esophagus can be reduced by topical anesthetics, analgesics,
and proton pump inhibitors, as well as dietary modification. Because nurses may not have
access to dieticians, they may have to create their own program to manage esophagitis. A third
important adverse effect of radiation in this setting is pneumonitis. The standard of care for
pneumonitis includes antibiotics, prednisone, and regular monitoring. Fibrosis also may occur
as a late effect of radiation-induced pneumonitis and requires ongoing surveillance and
treatment.
The most common dose-limiting factor for patients with lung cancer receiving radiotherapy is
radiation-induced damage to normal tissues, including the thorax area, skin, lungs, esophagus,
spinal cord, and heart. Although newer techniques (eg, intensity-modulated radiation therapy)
and the use of cytoprotective agents (eg, amifostine) allow higher doses with fewer acute
toxicities, nurses still need to educate patients on how they can help avoid adverse effects such
as skin toxicities, esophagitis, and pneumonitis and minimize pain. In this way, nurses can help
keep patients with NSCLC on track for treatment and avoid the need for treatment breaks.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Any patient receiving combined-modality therapy
presents the unique challenge of coordinating multispecialty care. Patients with NSCLC are
generally faced with a poor prognosis and limited treatment options. Effective management with
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![each regimen provides the best opportunity for an optimal outcome and will potentially preserve
future treatment options. Radiation plays an important role in the management of this patient
population but may be associated with significant toxicities and is generally limited to one-time
use for each treatment field. Therefore, aggressive proactive management of the most common
treatment-related toxicities is critical to providing the most effective treatment, limiting toxicity,
and improving quality of life. Recognition and management of acute toxicities is often the best
strategy to limit more severe and potentially irreversible toxicities in this patient population. The
investigation of protective agents, refinement of radiotherapy techniques, and improvement in
the early recognition and treatment of esophagitis, pneumonitis, esophageal stricture, and pain
have improved outcomes for patients receiving combined modality therapy for NSCLC.
Managing Pain in Patients with Cancer Receiving Radiotherapy
Tracy K. Gosselin, RN, MSN, AOCN: Another clinically important adverse effect of
radiotherapy is pain. A survey conducted by the Radiation Medicine Department of the North
Shore-Long Island Jewish Health System asked patients to rate how their pain was managed
during treatment on a scale of 1 (very poor) to 5 (very good).[58] An interdisciplinary team of
oncology nurses, a radiation oncologist, and a social worker assessed the scores from the
questionnaires and determined that a more in-depth pain assessment was needed. Therefore,
the investigators modified the satisfaction survey form to include the pain type, location,
duration, cause, and desired pain level.
The nursing staff found that the new assessment was easy to complete during patient visits and
that its more comprehensive information led to more comprehensive interventions for pain. The
investigators plan to implement personal pain diaries and develop an inpatient-specific pain
survey.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Pain is universally associated with decreased
quality of life and fatigue. However, it is often difficult to isolate the specific location, quality,
intensity, duration, exacerbating symptoms, and alleviating symptoms and thereby create
strategies to manage pain in individual patients. In addition, the subjective element of the
interpretation and tolerance of pain presents a challenge to the oncology nurse. Strategies for
pain management require an understanding of the underlying disease, the likelihood of pain
associated with the disease itself, and the treatment of the disease, as well as consideration of
the unique needs of individual patients. Continuity of care, including pain assessment, is critical
to determining the characteristics of pain and the best approach to treatment for each patient.
Evaluating and Treating Peripheral Neuropathy in Multiple Myeloma
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Oncology nurses play an important role in ensuring
proactive management of adverse effects related to novel agents. Faiman and colleagues[59]
conducted a study that assessed practice patterns of oncology nurses in the setting of
myeloma. The investigators used a 23-item survey, developed with expert oncology nurse input,
which was distributed to attendees of the 10th ONS Institute of Learning conference.
Approximately one half of respondents were staff nurses and nurse clinicians (53%), and 82%
of these had at least a bachelor’s degree. The survey focused on relevant aspects of adverse
effect monitoring, oncology nursing management, and general knowledge related to myeloma
and treatment with bortezomib, lenalidomide, PLD, and thalidomide.
Peripheral neuropathy is a major adverse effect of many newer therapies and was the most
frequently reported adverse effect of bortezomib and thalidomide in this survey. It also was
noted as being the most challenging adverse effect of those drugs to manage, often with the
help of anticonvulsant drugs and dose reductions.
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![Many practitioners (~ 85%) reported using gait/balance and touch/sensation to evaluate
neuropathy, but far fewer (33%) reported using a standardized assessment tool for peripheral
neuropathy symptoms. The data from this survey indicate that nurses need to learn more about
neuropathy evaluation in myeloma and, by extension, in other indications as well. The survey
authors commented that more effective nonpharmacologic prevention and treatment strategies
for peripheral neuropathy are needed.
Tracy K. Gosselin, RN, MSN, AOCN: Peripheral neuropathy can also affect patient safety.
When patients present with numbness/tingling and/or a gait/balance issue, it is important to
educate the patient and caregiver on the risk of falls and burns related to the changes in
sensation. Effects on a patient’s activities of daily living also affect quality of life; therefore, early
and ongoing education is important.
Managing Febrile Neutropenia in Patients with Cancer
Tracy K. Gosselin, RN, MSN, AOCN: Several abstracts presented at the congress were on the
topic of febrile neutropenia,[60-62] which, unfortunately, continues to be a significant issue in
many oncology settings despite the availability of growth factors. Although the incidence has
declined, patients can decompensate very quickly when it does occur. Febrile neutropenia can
delay treatment, increase the length of hospitalization, and decrease quality of life; it is a
potentially fatal emergency.[60,61]
Recommendations for patient education include explaining the white blood cell count and
absolute neutrophil count as part of complete blood count results; blood counts should be
required at each visit.[60] Patients should also be instructed to report when febrile episodes occur
and what to tell emergency department staff. Nurses at the University Medical Center in
Princeton, New Jersey, have developed a febrile neutropenia protocol that addresses patient
assessment, treatment options with time-sensitive parameters, and patient education.[61]
Using evidence-based practice, nurses at the USC Medical Center in Los Angeles developed
multidisciplinary guidelines and interventions designed to help patients with risk of neutropenia
avoid the need to visit the emergency room or hospitalization.[62] The chemotherapy ordering
process was updated with an area for ordering growth factors, which are recommended by the
NCCN for neutropenic patients.[63] The nurses included a clinical pathway that includes risk
factor guidelines to identify both those at risk and when to activate the action plan. Following 2
months of staff education, it was shown that patients at risk of neutropenia were cared for
better, including fewer admissions and early discharges. In addition, the recommended
prophylactic use of growth factors was shown to decrease both hospital visits and neutropenia-
specific admissions.
A complementary abstract covered evidence-based practice at the bedside.[64] Most bedside
nurses do not use an evidence-based approach, despite the availability of well-developed
evidence-based practice models. Nurses from the City of Hope hospital developed an evidence-
based practice model designed to address the practical needs of bedside nurses. Following 9
evidence-based practice workshops, nurses are now working on unit-based projects ranging
from symptom management to nurse-to-nurse communications.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Prophylactic risk–adapted treatment strategies for
patients at risk for febrile neutropenia have significantly reduced the incidence of
hospitalizations for patients receiving myelosuppressive therapies. Administration of granulocyte
colony–stimulating proteins based on identified risk factors including older age, bone marrow
involvement, radiation to marrow-producing sites (pelvis, sternum, ribs, calvarium, femurs),
splenectomy or splenic irradiation in patients with extramedullary hematopoiesis, and
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![chemotherapeutic regimens known to induce myelosuppression has reduced the incidence of
hospitalizations for febrile neutropenia. To be effective, however, the administration of growth
factors requires patient and caregiver education regarding reportable signs and symptoms, a
clear plan for discussion of laboratory values and symptoms, and implementation of a practice-
specific plan for identification of patients at high risk and prevention strategies for those
patients.
Maintaining Adherence to Novel Oral Agents
Tracy K. Gosselin, RN, MSN, AOCN: As all oncology nurses know, adherence to novel oral
agents is very important to producing the best possible outcomes in cancer patients. Siehl and
colleagues[65] conducted a comprehensive literature review, including results from an
international survey by the Multinational Association of Supportive Care in Cancer (MASCC),[66]
regarding adherence to oral therapies. Results showed that adherence rates can be as low as
20%. In my opinion, the low adherence is due in part to the specific patient population and in
part to how oral agents are prescribed. The investigators’ goal was to emphasize the value of
patient adherence by focusing on 3 key areas—knowledge, process, and responsibilities for
healthcare providers—and to identify ways to translate those into practice and thereby enhance
patient outcomes.
Results showed that nurses and other healthcare professionals need to have a shared
knowledge base related to information, a systematic process to employ for individual patients,
and clarity and consensus regarding roles and responsibilities. In this way, the value of
adherence can be recognized by both patient and provider. Although some centers successfully
enable good adherence by patients to oral agents, I think many struggle with it, in relation to
how well patients are doing and how effectively their symptoms are being managed. It is also
important for patients to feel comfortable enough to honestly answer how adherent they are to
their regimen.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Adherence is a challenge, especially with the new
oral agents. As former Surgeon General C. Everett Koop noted, “Drugs don’t work in patients
who don’t take them.”[67] Many patients with cancer fall outside the realm of nursing and may
have infrequent contact with oncology nurses. For instance, patients who are receiving
dasatinib or nilotinib for chronic myeloid leukemia come in to receive their oral medication and
then may not return to see their provider for a month, during which time adherence may falter.
Consistent exposure to treatment is key to bringing chronic myeloid leukemia under control.
This is an example of the challenge that oncology nurses face with a population of patients who
do not receive infusions and instead receive oral therapies for the treatment of their disease.
There are numerous related challenges. Not knowing when a patient has prescriptions filled and
when the patient starts therapy, ordering and review of laboratory tests obtained at outside
facilities, and the complexity of telephone contact create potential barriers to optimal therapy.
Strategies to mitigate adherence problems should be in place, such as chemotherapy education
classes for patients receiving oral agents and an established plan or calendar for scheduled
laboratory and clinic visits based on known risk profiles for individual treatment plans.
On the flip side, another problem with not seeing patients frequently is that those who are
consistently staying adherent to their regimen may not know when to stop based on adverse
effects; in other words, they may continue taking their regimen when treatment should be
interrupted. As providers and as nurses, it would be best in the early phase of illness to have
visits scheduled at more frequent intervals to monitor adherence and tolerance, and to improve
the efficacy and reduce the risk of treatment.
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![Tracy K. Gosselin, RN, MSN, AOCN: I agree. There are many patient factors related to their
disease, drug cost, age, social support, other comorbid diseases (eg, depression, cognitive
changes), and other issues that can potentially affect adherence. Seeing patients more
frequently makes sense.
Managing Oral Mucositis in Patients with Cancer Receiving Radiation
and/or Chemotherapy
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Oral mucositis refers to inflammatory tissue
damage of the oral cavity including the lips, tongue, gingiva, and the hard and soft palate. It is
an especially difficult adverse effect of treatment for many patients with cancer and can cause
pain, fatigue, depression, anxiety, difficulty sleeping, and changes in functional status.[68]
Approximately 40% of chemotherapy patients, 75% to 100% of patients receiving high-dose
chemotherapy during bone marrow transplantation, and 80% to 100% of patients receiving
radiation for head and neck cancer experience oral mucositis.[69,70]
Several years ago this was a hot topic in oncology, but as therapies were refined, oral mucositis
became limited mainly to patients undergoing bone marrow transplantation. However, with the
advent of new therapies, oral mucositis is becoming a problem again and is often
underestimated in terms of pain, anxiety, difficulty sleeping, depression, and being able to eat
and feel good.
Much like the difficulties with neuropathy, there are several different strategies practitioners use
for grading the different toxicities. These include guidelines such as the Oral Assessment
Guide,[71] Oral Mucosa Rating Scale,[72] Oral Mucositis Index,[73,74] and the Oral Mucositis
Assessment Scale.[69] Nurses should pay particular attention to the updated guidelines for the
prevention and treatment of mucositis from the MASCC/ISOO mucositis study group.[75]
However, the different guidelines are not necessarily consistent.
Most mucositis treatment relies on simple processes that do not require prescription
medications, including basic oral hygiene using bland oral rinses (eg, bicarbonate solution and
normal saline rinses), use of a soft toothbrush, and avoidance of aggravating factors. Other
options include low-level laser therapy, cryotherapy, and palifermin, which is available primarily
in the bone marrow transplant setting.[76] For systemic pain management, morphine is the
analgesic treatment of choice.[68] Topical anesthetics may provide temporary relief. It is
important for nurses to avoid the use of sucralfate, chlorhexidine, combination mouthwashes,
alcohol-containing compounds, and petroleum-based products.
Tracy K. Gosselin, RN, MSN, AOCN: Screening for and assessment of oral mucositis are
important for oncology nurses to understand in addition to treatment strategies. Risk factors
include a history of oral cavity problems, current oral health complications, and planned cancer
therapy.
Summary and Conclusions
Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Many of the sessions at the 2010 ONS Congress
tackled the difficult concepts of personalized medicine and targeted therapies. New pathways
being targeted for treatment were discussed, as were the associated unique toxicities that occur
in patients who have complex disease states. The overall question is how do we, as oncology
nurses, continue to play a major role in improving patient outcomes? How can nurses, including
oncology nurses, new nurses, and advanced-practice nurses, make a difference every day in
managing toxicities?
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![REFERENCES
1. National Cancer Institute. Colon and rectal cancer. Available at:
http://www.cancer.gov/cancertopics/types/colon-and-rectal. Accessed July 22, 2010.
2. Kinzler KW, Vogelstein B. Landscaping the cancer terrain. Science. 1998;280:1036-1037.
3. Rodriguez-Bigas MA, Boland CR, Hamilton SR, et al. A National Cancer Institute workshop on
hereditary nonpolyposis colorectal cancer syndrome: meeting highlights and Bethesda
guidelines. J Natl Cancer Inst. 1997;89:1758-1762.
4. Allen WL, Johnston PG. Role of genomic markers in colorectal cancer treatment. J Clin Oncol.
2005;23:4545-4552.
5. Benatti P, Gafà R, Barana D, et al. Microsatellite instability and colorectal cancer prognosis. Clin
Cancer Res. 2005;11:8332-8340.
6. Jo WS, Carethers JM. Chemotherapeutic implications in microsatellite unstable colorectal cancer.
Cancer Biomark. 2006;2:51-60.
7. Karapetis CS, Khambata-Ford S, Jonker DJ, et al. K-ras mutations and benefit from cetuximab in
advanced colorectal cancer. N Engl J Med. 2008;359:1757-1765.
8. Erbitux [package insert]. Branchburg, NJ: ImClone Systems, Inc; 2009.
9. Vectibix [package insert]. Thousand Oaks, CA: Amgen; 2009.
10. National Comprehensive Cancer Network. Clinical practice guidelines in oncology: colon cancer
(v.3.2010). Available at: http://www.nccn.org. Accessed July 22, 2010.
11. Carmen JA, Jessup JM, Somerfield MR, et al. American Society of Clinical Oncology provisional
clinical opinion: testing for KRAS gene mutations in patients with metastatic colorectal carcinoma
to predict response to anti–epidermal growth factor receptor monoclonal antibody therapy. J Clin
Oncol. 2009;21:9170.
12. Peltomäki P, Vasen H. The International Collaborative Group on Hereditary Nonpolyposis
Colorectal Cancer. Mutations predisposing to hereditary nonpolyposis colorectal cancer:
database and results of a collaborative study. Gastroenterology. 1997;113:1146-1158.
13. Vasen HF, Watson P, Mecklin JP, Lynch HT. New clinical criteria for hereditary nonpolyposis
colorectal cancer (HNPCC, Lynch syndrome) proposed by the International Collaborative Group
on HNPCC. Gastroenterology. 1999;116:1453-1456.
14. Martinez-Balibrea E, Abad A, Martinez-Cardus A, et al. UGT1A and TYMS genetic variants
predict toxicity and response of colorectal cancer patients treated with first-line irinotecan and
fluorouracil combination therapy. Br J Cancer. 2010;[E-pub ahead of print].
15. National Quality Forum. NQF-Endorsed Standards. Adjuvant chemotherapy is considered or
administered within 4 months (120 days) of surgery to patients under the age of 80 with AJCC III
(lymph node positive) colon cancer. NQF #0223. http://www.qualityforum.org.
16. Compton C, Fenoglio-Preiser CM, Pettigrew N, et al. American Joint Committee on Cancer
Prognostic Factors Consensus Conference: Colorectal Working Group. Cancer. 2000;88:1739-
1757.
17. Lee SA, Kwon HC, Park MA, et al. Impact of the new AJCC staging system and adjuvant
treatment in rectal cancer. Cancer Res Treat. 2004;36:121-127.
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2010 Oncology Nursing Society Congress
The 35th Annual Oncology Nursing Society Congress focused on advancements in oncology nursing, specifically addressing individualized care in colorectal cancer, risk management strategies, and safety standards in chemotherapy. The conference highlighted the importance of genetic testing in treatment decision-making and the role of risk evaluation and mitigation strategies (REMS) in managing drug-related risks. Key objectives included enhancing clinicians' knowledge of novel therapies and ensuring optimal patient outcomes through informed nursing interventions.
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2010 Oncology Nursing Society Congress
- 1. CONFERENCE REPORT 35th AnnualOncology Nursing Society Congress: Conference Report CCO Independent Conference Coverage of the 2010 Oncology Nursing Society Congress * *CCO is an independent medical education company that provides state-of-the-art medical information to healthcare professionals through conference coverage and other educational programs. FACULTY STAFF Tracy K. Gosselin, RN, MSN, AOCN Gordon Kelley Clinical Associate Senior Clinical Editor, Duke University School of Nursing Hematology/Oncology Assistant Vice President, Oncology Services Clinical Care Options, LLC Duke University Health System Durham, North Carolina Edward King, MA Vice President, Editorial Sandra E. Kurtin, RN, MS, AOCN, ANP-C Clinical Care Options, LLC Hematology/Oncology Nurse Practitioner Clinical Assistant Professor of Nursing Andrew D. Bowser Clinical Assistant Professor of Medicine Editorial Director, Arizona Cancer Center Hematology/Oncology University of Arizona Clinical Care Options, LLC Tucson, Arizona Jim Mortimer Senior Director, Oncology Programs and Partnership Development Hematology/Oncology Clinical Care Options, LLC Christopher K. Taylor, PhD Contributing Editor Jointly sponsored by Jointly sponsored by Annenberg Center for Health Sciences at Eisenhower and Clinical Care Options, LLC This activity is supported by educational grants from: Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 1
- 2. DISCLOSURE OF CONFLICTSOF INTEREST The Annenberg Center assesses conflict of interest with its instructors, planners, managers and other individuals who are in a position to control the content of CME activities. All relevant conflicts of interest that are identified are thoroughly vetted by the Annenberg Center for fair balance, scientific objectivity of studies utilized in this activity, and patient care recommendations. The Annenberg Center is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest. The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME activity: Gordon Kelley has no significant financial relationships to disclose. Tracy K. Gosselin, RN, MSN, AOCN, has no significant financial relationships to disclose. Sandra E. Kurtin, RN, MS, AOCN, ANP-C, has no significant financial relationships to disclose. Gordon Kelley has no significant financial relationships to disclose. Edward King, MA, has no significant financial relationships to disclose. Andrew D. Bowser has no significant financial relationships to disclose. Jim Mortimer has no significant financial relationships to disclose. Christopher K. Taylor, PhD, has no significant financial relationships to disclose. The planners and managers reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME activity: The following planners and managers, Jan Hixon, RN, BSN, MA; Trace Hutchison, PharmD; Julia Kimball, RN, BSN; Samantha Mattiucci, PharmD; Jan Schultz, RN, MSN, CCMEP; Patricia Staples, MSN, NP-C, CCRN and Gordon West, PhD, CCMEP, hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months. DISCLOSURE OF UNLABELED USE This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The Annenberg Center, Postgraduate Institute for Medicine (PIM), Clinical Care Options, and activity supporters do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the Annenberg Center, PIM, Clinical Care Options, and activity supporters. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. DISCLAIMER Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 2
- 3. TARGET AUDIENCE This activityis intended for oncology nurses, advanced-practice nurses, and other healthcare professionals involved in the care of patients with cancer. GOAL The goal of this activity is to improve clinicians’ knowledge and/or competence in the areas of novel cancer therapies, survivorship and late effects of cancer treatment, and strategies to optimize clinical outcomes through nursing interventions. LEARNING OBJECTIVES Upon completion of this activity, participants should be able to: Recommend molecular or genetic testing to guide treatment for patients with colorectal cancer Apply risk evaluation and mitigation strategies to the management of patients with cancer Understand safety standards for the administration of chemotherapy agents to avoid exposure to hazardous drugs Explain the benefits and adverse effects of novel agents to patients with cancer Incorporate management of chemotherapy- and radiotherapy-induced toxicities into patient care Review options for management of febrile neutropenia with patients at risk of neutropenia Provide appropriate care and counsel for patients and their families NURSING CONTINUING EDUCATION Accreditation Statement Annenberg Center for Health Sciences is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Credit Designation A maximum of 0.9 contact hours may be earned for successful completion of this activity. INSTRUCTIONS FOR CREDIT Participation in this self-study activity should be completed in approximately 0.9 hours. To successfully complete this activity and receive credit, participants must follow these steps during the period from August 31, 2010 through August 30, 2011: 1. Register online at http://clinicaloptions.com 2. Read the target audience, learning objectives, and faculty disclosures. 3. Study the educational activity online or printed out. 4. Submit answers to the posttest questions and evaluation questions online. You must receive a test score of at least 70% and respond to all evaluation questions to receive a certificate. After submitting the evaluation, you may access your online certificate by selecting the certificate link on the posttest confirmation page. Records of all CME activities completed can be found on the "My CME" page. There are no costs/fees for this activity. DISCLAIMER The materials published on the Clinical Care Options Web site reflect the views of the reviewers or authors of the CCO material, not those of Clinical Care Options, LLC, the CME provider, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials. Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 3
- 4. 35th Annual OncologyNursing Society Congress: Conference Report CONTENTS Introduction ................................................................................................................................... 5 Colorectal Cancer: Individualized Care......................................................................................... 5 Managing Risks in Cancer Patients Using Risk Evaluation and Mitigation Strategies ................. 6 ONS/ASCO Chemotherapy Safety Standards .............................................................................. 8 Immunotherapy for Advanced Melanoma ..................................................................................... 9 Personalized Treatment in Liver Cancer ..................................................................................... 10 Progress in Ovarian Cancer ........................................................................................................ 11 Chemotherapy in the Perioperative Setting ................................................................................ 12 Managing Acute Toxicities During Radiation Treatment of Non-Small-Cell Lung Cancer .......... 13 Managing Pain in Patients with Cancer Receiving Radiotherapy ............................................... 14 Evaluating and Treating Peripheral Neuropathy in Multiple Myeloma ........................................ 14 Managing Febrile Neutropenia in Patients with Cancer .............................................................. 15 Maintaining Adherence to Novel Oral Agents ............................................................................. 16 Managing Oral Mucositis in Patients with Cancer Receiving Radiation and/or Chemotherapy ............................................................................................................................ 17 Summary and Conclusions ......................................................................................................... 17 Posttest ....................................................................................................................................... 19 References.................................................................................................................................. 20 Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 4
- 5. Introduction The 35th AnnualOncology Nursing Society (ONS) Congress was held May 13-16, 2010, in San Diego, California. This Conference Report reviews current topics of interest to oncology nurses, including both treatment and supportive care. Tracy K. Gosselin, RN, MSN, AOCN, and Sandra E. Kurtin, RN, MS, AOCN, ANP-C, discuss the relevance to clinical practice of some of the most important topics discussed at the meeting. Topics include the use of molecular and genetic testing to guide treatment for patients with colorectal cancer, risk evaluation and management strategies, safety standards for the administration of chemotherapy agents, the benefits and adverse effects of novel agents, management of chemotherapy-induced and radiotherapy-induced toxicities, and management of neutropenia. A key take-home message is that oncology nurses need to fully understand a patient’s treatment regimen, understand patients as individuals, assess comorbidities, and determine how likely a patient is to respond to a given therapy for his or her tumor type. Colorectal Cancer: Individualized Care Tracy K. Gosselin, RN, MSN, AOCN: Colorectal cancer is the third most common cancer among men and women in the United States. It is estimated that in 2010, more than 142,000 new cases of colorectal cancer will be diagnosed, leading to more than 51,000 deaths.[1] Nurses managing patients with colorectal cancer have multiple patient-specific factors to contend with that can influence a patient’s experience and outcomes. Common modifiable and nonmodifiable risk factors in patients with colorectal cancer include exercise level, diet, and body mass index. Measures to reduce these risks, as well as screening, identification of prognostic factors, understanding the development of colorectal cancer (eg, Vogelstein’s pathway[2]) and managing toxicities, are key to optimal patient care. Testing for predictive or prognostic biomarkers, including microsatellite instability,[3] genomic aberrations, and the presence or absence of proteins, is becoming an important part of individualizing care in the setting of colorectal cancer. Different testing criteria are used depending on personal and family histories. Perhaps the most important test is to determine whether KRAS is mutated—approximately 40% of colorectal cancer patients have a KRAS mutation linked to increased risk of nodal metastasis and potentially more aggressive tumor behavior.[4-6] Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Determining whether a patient has wild-type or mutant KRAS also dictates whether or not anti–epidermal growth factor receptor (EGFR) monoclonal antibodies are used in treatment, as mutations in codons 12 and 13 in exon 2 of KRAS confer resistance to treatment with EGFR inhibitors.[7-9] The National Comprehensive Cancer Network (NCCN) now recommends that testing for KRAS mutations be conducted before treatment with cetuximab or panitumumab, the 2 anti-EGFR antibodies used today in the treatment of colorectal cancer.[10] The American Society of Clinical Oncology (ASCO) issued a provisional opinion recommending that patients with metastatic colorectal cancer and KRAS mutations in codon 12 or 13 not receive anti-EGFR antibody therapy.[11] Testing for KRAS mutations can spare affected patients the cost and toxicity of an ineffective treatment. Tracy K. Gosselin, RN, MSN, AOCN: Other tests used to individualize treatment of patients with colorectal cancer include immunohistochemical staining to identify 4 mismatch repair (MMR) proteins with prognostic significance; if 1 or more are absent in tumor tissue, there is cause for concern. In hereditary nonpolyposis colorectal cancer, the most common form of inherited colorectal cancer, detection of the causal alteration of the MMR gene involved is essential for proper management of the disease. Detection of this alteration allows the Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 5
- 6. identification of relativeswho are at high risk for colorectal or endometrial cancer and who therefore require appropriate screening. Determining whether family members have the MMR alteration can also avert useless surveillance in noncarriers. Mutational studies based on conventional screening methods have indicated that point mutations of the MMR genes MSH2, MLH1, or MSH6 can be detected in approximately 55% of families with hereditary nonpolyposis colorectal cancer.[12,13] Sandra E. Kurtin, RN, MS, AOCN, ANP-C: These changes in patient assessment have affected the colorectal cancer population that I work with. Colorectal cancer as a diagnosis is a broad umbrella, and some areas under that umbrella are still being identified. This includes risk factors—young patients in their 20s are presenting with metastatic disease, so understanding why that is happening, including what is going on at the molecular level within the tumors, is critical. One reason this is important is that certain molecular abnormalities can predispose patients to significant toxicities. For example, microsatellite instability is used to guide whether a patient with low-grade disease should be treated or not. Patients with early stage colorectal cancer (high-risk stage II) who are positive for microsatellite instability may actually have an increased risk of recurrence when exposed to 5-fluorouracil agents used commonly in adjuvant therapy for high-risk disease. In this setting, patients who are homozygous for the UGT1A1*28 allele have an increased risk of developing severe neutropenia when receiving irinotecan.[14] Molecular assays are available to identify at-risk subgroups, although widespread use is not common. More often, patients who experience unusual toxicity are tested for the UGT1A1*28 allele; if it is present and homozygous, subsequent doses may be modified. Tracy K. Gosselin, RN, MSN, AOCN: These changes in assessment of colorectal cancer patients are reflected in the NCCN guidelines,[10] which recommend screening patients for mutations in KRAS, BRAF, and MMR genes and for microsatellite instability. For patients receiving chemotherapy for colon cancer, nurses should apply the National Quality Forum quality measures,[15] which reflect the transition of medical care toward more individualized treatment strategies. The American College of Surgeons’ Commission on Cancer guidelines for the staging of colon cancer and the NCCN guidelines are also important for nurses to be aware of.[10,16,17] In the past, treatment of colorectal cancer and other malignancies was individualized based on a pathology report, radiology films, and laboratory studies. Now, with the identification of biomarkers such as MMR and KRAS alterations, it is increasingly important for oncology nurses and advanced-practice nurses to understand how these novel factors relate to staging and treatment. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Yes, nurses need to become familiar with the pathophysiology of colorectal cancer and thereby understand why different newly diagnosed patients may require very different approaches to therapy based on tissue analysis. Managing Risks in Cancer Patients Using Risk Evaluation and Mitigation Strategies Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Risk evaluation and mitigation strategies (REMS) are used to manage known or potential serious risks with a drug or biologic therapy.[18] REMS may be required if deemed necessary by the US Food and Drug Administration (FDA) to ensure that the benefits of an agent outweigh the risks and may be required before or after approval. For example, newly recognized risks, new findings concerning a known adverse drug reaction, Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 6
- 7. or changes infrequency or severity of risk factors may be reasons to implement postapproval REMS programs.[19] Tracy K. Gosselin, RN, MSN, AOCN: From a provider or prescriber standpoint, REMS can be confusing. The 3 main categories of REMS are[18]: • Medication guide (patient package insert) • Communication plan for healthcare provider • Elements to ensure safe use The different elements of REMS include the implementation of systems, special labeling requirements, postapproval studies, and an assessment timetable. Nursing concerns regarding REMS include training and educational requirements, cost and time involved, and the fact that there are different REMS requirements for each agent. Areas of concern exist for prescribers and staff as well, related to the effect of REMS on the multidisciplinary team. Prescribers need to be aware of emerging changes in REMS and REMS requirements, not only in a broad sense but also for each therapeutic agent. Settings such as infusion centers may be required to distribute educational materials to patients. REMS also affect patients, who may have concerns about decreased access for treatment stemming from cost, fear, and limited locations that can dispense certain drugs.[20,21] Indeed, even before the development of REMS, there have been issues with patients gaining access to necessary treatment. This is an interesting area of oncology nursing; in the future, the number of therapies with REMS requirements could affect drug distribution systems as well as access by patients. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: REMS are widely implemented, for example, in patients receiving erythropoiesis-stimulating agents (ESAs); the 2 ESAs approved in the United States are epoetin alfa and darbepoetin alfa. ESAs are often used to treat patients with anemia but have been associated with increased risk of tumor growth and decreased survival in patients with cancer, as well as risks of heart attack, heart failure, stroke, and blood clots.[22] The Assisting Providers and Cancer Patients with Risk Information for the Safe Use of ESAs REMS program is required for all healthcare providers prescribing or dispensing ESAs (http://www.esa- apprise.com). Completing the training module takes approximately 15 minutes. The module describes adverse outcomes seen with ESAs, describes appropriate use of ESAs for patients with cancer (eg, only if hemoglobin is ≥ 10 g/dL, only in patients receiving myelosuppressive chemotherapy, only in nonmyeloid malignancies), and sets out the requirements for healthcare providers[23]: • Provide patient education guides from the manufacturer every time an ESA is dispensed • Conduct a risk/benefit discussion with the patient, including addressing patient questions and concerns, and fill out a form showing they have done so • Inform each patient that ESAs are associated with increased mortality, serious cardiovascular and thromboembolic events, and increased tumor progression or recurrence REMS are required or recommended for more than 100 drugs in many other classes of drugs as well, including the opioids (eg, fentanyl, morphine, oxycodone), which carry risks of misuse, abuse, and accidental overdose. For this class of drugs, physician education is voluntary, and Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 7
- 8. the manufacturers providepatient education materials to be used during patient counseling sessions. The opioid REMS are currently (2010) undergoing revision by the FDA.[24] REMS are also required for the immunomodulatory agents thalidomide and lenalidomide owing to historical data associating thalidomide with birth defects (teratogenicity). Although no cases of birth defects have been reported for lenalidomide, it has been included in the REMS program due to the similar molecular structure and mechanism of action of the drugs. Both thalidomide and lenalidomide may be obtained only after completion of a screening and safety program. Oncology nurses apply REMS on a daily basis as part of their ongoing management of the potential risks of a therapy. Physicians and nursing staff must know and communicate the risks and benefits of a given therapy. However, implementing REMS can become overwhelming due to its complexity; in some cases, providers will decide that REMS make a therapy too difficult to use, which can limit access to a beneficial agent. Tracy K. Gosselin, RN, MSN, AOCN: For instance, blood transfusion rates have begun to increase, in part due to the implementation of REMS, which result in not being able to use ESAs as freely as with previous established safety guidelines.[25] ONS/ASCO Chemotherapy Safety Standards Tracy K. Gosselin, RN, MSN, AOCN: The ONS and ASCO have developed safety standards for administration of chemotherapy agents.[26] The criteria for these standards were that they should be applicable to diverse practice settings, understandable and clinically intuitive, realistic to achieve, evidence based, reliable, measureable, and actionable. The 31 standards encompass 7 domains, each with several areas specific to the different steps in chemotherapy administration: • Review of clinical information and selection of treatment regimen • Treatment planning and informed consent • Ordering of treatment • Drug preparation • Assessment of treatment compliance • Administration and monitoring • Assessment of response and toxicity monitoring The standards set forth help nurses understand the complex process of chemotherapy administration, including the facility type and available resources. Interestingly, the new standards include considerations regarding oral chemotherapy agents, and may affect how institutions manage these agents. For example, verification is required of the drug name, dose, volume, expiration, and appearance/physical integrity. The guidelines also discuss optimal use of a variety of different methodologies related to monitoring and assessment of treatment with chemotherapies. For instance, during each clinical visit, staff should document changes in patient clinical status, weight, and performance status, as well as psychosocial concerns and need for support. Nurses also need to document and record changes in the patient’s current medications, including over-the-counter, complementary, and alternative therapies. Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 8
- 9. As these standardsare incorporated into ASCO’s Quality Oncology Practice Initiative,[27] it will be important to carefully look at how they are implemented in clinical practice to mitigate risk. This may require institutions to conduct failure mode effect analysis and process mapping to understand their process regarding chemotherapy, and to identify the risks and the practice gaps. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Chemotherapy safety standards need to be applicable to the variety of settings seen in oncology practices today. The standards must allow practitioners to maintain safety but not become so stringent that they are more suited to an academic setting where there are many more people and more resources. Putting these standards into practice is definitely challenging. For example, in a small community practice where an oncology nurse may mix and administer chemotherapeutic agents for multiple patients each day, application of the safety standards (eg, use of specialty gloves, gown, mask) may impede efficiency and increase costs to the practice. Although the safety of the nurse and of the patient is the primary concern, further studies are necessary to promote practices that both provide for safety and are feasible in a wide variety of settings. Immunotherapy for Advanced Melanoma Tracy K. Gosselin, RN, MSN, AOCN: A survey was presented that looked at the practice patterns of nurses with regard to immunotherapy for advanced melanoma.[28] Nurses filled out a 16-item questionnaire covering demographics, nursing knowledge, attitudes, and practice behaviors. The sample size was 60 nurses, 51% of whom held a master’s degree. Sixty-four percent of respondents reported using interferon alfa-2b for the adjuvant treatment of stage III melanoma; this finding is unsurprising given that melanoma does not have a wide armamentarium of agents to use for treatment. Approximately 20% reported combination chemotherapy plus interleukin (IL)-2 as the most commonly used treatment for stage IV disease. Interestingly, 40% of respondents noted that they did not have institutional guidelines to manage the adverse effects for immunomodulatory targeted agents. Yet, good information regarding the management of adverse effects is available, indicating a gap in translating evidence into practice. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: The newer targeted therapies are being refined and are expanding into specific diagnostic groups in diseases that are outside of the typical chemotherapeutic administration setting for many practices. A community practice may see only 1 or 2 patients with a particular disease, and it can be challenging to readily access information regarding adverse effects of novel therapies in this situation. Tracy K. Gosselin, RN, MSN, AOCN: This study provides an interesting look at how nurses, especially advanced-practice nurses, treat melanoma. Unfortunately, the incidence of melanoma is rising—by nearly 3% per year since 1980.[29,30] Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Yes, which means more nurses need education regarding the treatment of melanoma, including information regarding newer drugs that are becoming more widely available. Many novel therapeutic strategies are under investigation for the treatment of melanoma, including the following: • Peptide vaccination plus IL-2: phase III data regarding the gp100:201-217 vaccine showed significant improvements in response rates and progression-free survival (PFS) vs IL-2 alone[31] Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 9
- 10. • BRAF kinase inhibition: phase I data regarding a selective inhibitor of the oncogenic V600E mutant BRAF kinase, PLX4032, suggest the potential for improved responses and tumor progression[32] • Angiogenesis inhibition: the combinations of dacarbazine and bevacizumab,[33] and carboplatin/paclitaxel and bevacizumab,[34] as well as the soluble vascular endothelial growth factor receptor aflibercept[35] have shown promising clinical activity Personalized Treatment in Liver Cancer Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Liver cancer is one of the most common cancers throughout the world, with an overall 5-year survival of approximately 2%.[36] In the United States, more than 24,000 new cases of liver cancer (including intrahepatic bile duct cancer) are expected to be diagnosed in 2010, with nearly 19,000 deaths.[29] The risk factors for liver cancer include cirrhosis (eg, from alcohol abuse, autoimmune disease, or hepatitis B or C), diabetes, and obesity. Inherited liver-related diseases include hemochromatosis, Wilson’s disease, and biliary atresia.[36] Once diagnosed, liver cancers are staged according to the Child-Pugh classification,[37] which is based on the severity of chronic liver disease, typically cirrhosis, according to the degree of ascites, plasma concentrations of bilirubin and albumin, prothrombin time, and the degree of hepatic encephalopathy. An online calculator of Child-Pugh score can be found at http://depts.washington.edu/uwhep/calculations/childspugh.htm. Patients with liver cancer are also staged according to the tumor-node-metastasis staging system, in which stage I-II is confined to the liver, stage IIA-C is near the liver and includes lymph nodes, and stage IV represents metastasis beyond the liver. Historically, treatment options have been very limited and primarily relied on surgical resection. As a result, many patients are treated by hepatologists or liver surgeons rather than medical oncologists or oncology nurses. Tracy K. Gosselin, RN, MSN, AOCN: Also, if patients with liver cancer are not staying in a surgical oncology unit after the procedure, they may not be seen by medical oncologists or oncology nurses. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Modern treatment options for patients with liver cancer include not only surgery, but also embolization, ablation, radiation, targeted therapies, chemotherapy, and hepatic arterial infusion. However, to date, the sole curative treatments are surgical resection and transplantation.[38] These are not options for the majority of patients. Therefore, the use of liver-directed therapies has allowed many of these patients to live far beyond their previously estimated life expectancy. Molecularly targeted agents are now used as adjuvant therapy to treat liver cancer. For example, the tyrosine kinase inhibitor sorafenib has been approved for the treatment of hepatocellular carcinoma. Sorafenib binds multiple targets, including components of the Raf/MEK/ERK pathway, which has been implicated in hepatic tumorigenesis.[39] Mammalian target of rapamycin (mTOR) inhibitors are another promising class of targeted therapies for the treatment of hepatic disease.[40] The mTOR protein allows progression from the G1 to S phases and is a central regulator of cell growth and proliferation,[41] and the PI3K/Akt/mTOR pathway is implicated in the pathogenesis of hepatocellular carcinoma.[42,43] Clinically available mTOR inhibitors used for the treatment of liver cancer include sirolimus, temsirolimus, and everolimus.[44] Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 10
- 11. Tracy K. Gosselin,RN, MSN, AOCN: With regard to embolization, nurses need to be aware that the different types of agents (radiotherapy or chemotherapy, including microspheres) have different safety criteria related to safe handling and administration. Embolic agents used in liver cancer include bland materials such as gelfoam and starch microspheres, chemotherapies (eg, cisplatin, mitomycin), radiopharmaceuticals (eg, Y90 microspheres), and alcohol. Embolic agents are typically administered through the hepatic artery, but portal vein embolization is also used to create hypertrophy in the nondiseased liver, thereby increasing potential liver function.[45] Sandra E. Kurtin, RN, MS, AOCN, ANP-C: In liver cancer, as in other malignancies, an interdisciplinary approach to care is increasingly called for. For any given patient with a cancer diagnosis, a multitude of specialties may be involved along with the support staff, nurses, and other practitioners who interact with the patient. For instance, liver-directed therapies for hepatocellular carcinoma are now being used in other diseases that metastasize to the liver, such as colorectal cancer, to offer more strategies for treatment. Similarly, treatment with mTOR inhibitors and multitargeted tyrosine kinase inhibitors was initially used only in renal cell carcinoma but is now expanding into other diagnostic groups, including hepatocellular carcinoma and some hematologic malignancies. The toxicity profiles for these agents (eg, hand- foot syndrome, hyperkeratosis, hypertension, fatigue, and cramping) present a challenge to oncology nurses. As advances in understanding of these diseases are made and interdisciplinary strategies for treatment are expanded, nurses are more likely to encounter therapies originally developed for patients not commonly seen in the oncology nursing arena. Therefore, nurses need to remain educated regarding evolving interdisciplinary cancer care to become more comfortable with the complex concepts and processes. Personalized medicine is the way of the future. Progress in Ovarian Cancer Tracy K. Gosselin, RN, MSN, AOCN: In 2010, more than 21,000 women are expected to be diagnosed with ovarian cancer, with more than 13,000 deaths, making it the fifth leading cause of cancer-related death among women.[29] Many advancements in ovarian cancer treatment have been made in recent years including improved surgical staging, understanding the importance of cytoreductive surgery, molecular profiling, and the use of first-line chemotherapy, especially combination therapy, for late-stage disease. It can be difficult to determine optimal treatment for patients with chronic disease, as it is unclear whether they should receive surgery or a platinum-free interval. If they have platinum-resistant disease, subsequent treatment options are limited. There are only a few agents with efficacy in ovarian cancer, and much research is under way seeking to change this. Anastasia and colleagues[46] summarized clinical trials that have provided progress in first-line therapies, including a phase II study of the poly(ADP-ribose) polymerase (PARP) inhibitor olaparib; PARP repairs DNA damage in cancer cells.[47] In this study, 57 patients with BRCA-deficient advanced ovarian cancer were randomized to olaparib at either 400 mg or 100 mg twice daily. Interim results showed that the overall response rate was substantially higher in the higher-dose group (33%) than in the lower-dose group (13%). The clinical benefit rate (overall response rate and/or confirmed ≥ 50% decline in CA-125) was 58% vs 17%, respectively. It will be a very positive advance in this setting if these positive phase II data are confirmed in larger, randomized studies of olaparib. The anti–vascular endothelial growth factor antibody bevacizumab, which has shown efficacy in many other tumor types, is now being investigated for the treatment of ovarian cancer. Several phase II studies have shown response rates to bevacizumab of 16% to 24%, with stable disease being achieved by more than 50% of patients in each trial.[48-50] In these studies, 6- Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 11
- 12. month PFS rangedfrom 28% to 56%, and median overall survival was approximately 11-17 months. Nurses will need to be aware of the unique toxicities of this agent, including gastrointestinal perforation, arterial thromboembolic events, grade 3 hypertension, deep vein thrombosis/pulmonary embolism, bleeding, and wound-healing complications. Another promising novel agent being investigated in ovarian cancer is trabectedin, which interferes with nucleotide excision repair processes and thereby induces lethal double-strand DNA breaks and blocks the cell cycle in the G2 phase. Results from the large OVA-301 phase III study[51] recently showed that the addition of trabectedin to pegylated liposomal doxorubicin (PLD) as second-line therapy significantly improved response rates in patients with ovarian cancer from 19% to 28% (P = .008). The primary endpoint, median PFS, was 7.3 months with trabectedin/PLD vs 5.8 months with PLD alone (P = .0190). Among patients with a platinum-free interval of 6-12 months (ie, partially platinum sensitive), PFS, overall survival, and overall response rate were all improved with the addition of trabectedin.[52] This combination has been approved in Europe and is under review by the FDA in the United States. The most common adverse reactions to trabectedin include neutropenia, nausea, vomiting, increases in aspartate aminotransferase/alanine transaminase, anemia, fatigue, thrombocytopenia, anorexia, and diarrhea. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: The treatment of ovarian cancer is becoming more complex, requiring familiarity with techniques for alternative routes of treatment (eg, intraperitoneal) as well as the potential toxicities associated with each route. For example, it is important to take into account the different mechanisms of action of individual drugs, whether therapies are complementary or more effective in combination, and the potential for enhanced toxicity with this approach. Preserving future treatment options by vigilant monitoring of common toxicities and application of prevention strategies will allow each patient the best opportunity to receive all available therapies. The steady emergence of novel agents requires that nurses stay current with new thinking in this difficult disease. Tracy K. Gosselin, RN, MSN, AOCN: In ovarian (and other) cancers, the personalized oncology continuum involving genomics, proteomics, gene-expression profiling, and chemosensitivity testing is likely to continue driving future advances. Those advances are dependent on clinical trials, however, and only approximately 3% of adult cancer patients are enrolled in clinical trials.[53] There are substantial barriers to clinical trial participation, including how patients access care, provider and patient awareness of trials, and patient preference.[54] Chemotherapy in the Perioperative Setting Tracy K. Gosselin, RN, MSN, AOCN: The concerns regarding use of chemotherapy in the perioperative setting are environmental contamination, safety of staff, and protective measures. Oncology nurses need to be familiar with the previously discussed ASCO/ONS chemotherapy safety standards.[26] The National Institute for Occupational Safety and Health has also issued guidelines for chemotherapy management in the perioperative setting, including safe handling, personal protective equipment, and medical surveillance.[55] These include avoiding skin contact with hazardous drugs, cleaning and decontamination procedures, and preparation in a ventilated cabinet. Typically, nurses and physicians gain knowledge about chemotherapy from their experience in an in-patient oncology unit or an infusion suite. However, the same chemotherapy safety standards and principles are also important in an operating room platform. Nurses need to be aware of different ways chemotherapy is used in the perioperative setting, including peritoneal bathing, periocular administration, isolated (regional) limb infusion/perfusion, intracranial (glial wafer) administration, intraperitoneal catheter, and intravesicular administration.[56] Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 12
- 13. These factors affectpatient preparation in the operating room, how long the patients might remain in the operating room, and positioning for surgical procedures. Because patients with cancer can have a variety of comorbid diseases, the positioning of patients with diabetes, neuropathies, or other nerve issues needs to be carefully considered owing to the potential postoperative complications (injury or paralysis) that could arise, in addition to the chemotherapy safety standards. This issue is particularly important when patients might be in a surgical position for 4-8 or even 12-24 hours. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Good point. Another significant concern regarding chemotherapy is the potential for chemotherapy-induced neuropathy. Within the primary cancer groups (eg, gastric, colorectal, ovarian, and peritoneal cancers, and the lymphoid malignancies), patients often receive drugs that cause neuropathy. The most common agents associated with chemotherapy-induced neuropathy are the platinum-containing compounds such as oxaliplatin and cisplatin, the taxanes (paclitaxel and docetaxel), the vinca alkaloids (vincristine and vinblastine), and the proteasome inhibitor bortezomib. Advances in surgical technologies and the ability to conduct very fine procedures allow today’s patients a wider range of treatment options than previously available. It will be interesting to see how these changes affect individual comorbidities, disease outcomes, and quality of life, as well as the ability to later treat the patient for systemic disease. Managing Acute Toxicities During Radiation Treatment of Non-Small- Cell Lung Cancer Tracy K. Gosselin, RN, MSN, AOCN: Management of acute toxicities during radiation treatment of non-small-cell lung cancer (NSCLC) is challenging for oncology nurses.[57] The adverse effects of radiation can be debilitating and affect the patient’s well-being and quality of life. For example, cutaneous toxicities such as erythema, blistering, and both moist and dry desquamation can cause the patient discomfort and pain, particularly if there is skin breakdown. Nurses can recommend appropriate skin care to patients, including avoiding sunlight and chemical irritants, as well as the use of skin care guidelines that promote bathing and the use of provider-recommended products. Radiation-induced esophagitis usually develops 2-3 weeks after the patient receives external beam radiation. Irritation to the esophagus can be reduced by topical anesthetics, analgesics, and proton pump inhibitors, as well as dietary modification. Because nurses may not have access to dieticians, they may have to create their own program to manage esophagitis. A third important adverse effect of radiation in this setting is pneumonitis. The standard of care for pneumonitis includes antibiotics, prednisone, and regular monitoring. Fibrosis also may occur as a late effect of radiation-induced pneumonitis and requires ongoing surveillance and treatment. The most common dose-limiting factor for patients with lung cancer receiving radiotherapy is radiation-induced damage to normal tissues, including the thorax area, skin, lungs, esophagus, spinal cord, and heart. Although newer techniques (eg, intensity-modulated radiation therapy) and the use of cytoprotective agents (eg, amifostine) allow higher doses with fewer acute toxicities, nurses still need to educate patients on how they can help avoid adverse effects such as skin toxicities, esophagitis, and pneumonitis and minimize pain. In this way, nurses can help keep patients with NSCLC on track for treatment and avoid the need for treatment breaks. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Any patient receiving combined-modality therapy presents the unique challenge of coordinating multispecialty care. Patients with NSCLC are generally faced with a poor prognosis and limited treatment options. Effective management with Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 13
- 14. each regimen providesthe best opportunity for an optimal outcome and will potentially preserve future treatment options. Radiation plays an important role in the management of this patient population but may be associated with significant toxicities and is generally limited to one-time use for each treatment field. Therefore, aggressive proactive management of the most common treatment-related toxicities is critical to providing the most effective treatment, limiting toxicity, and improving quality of life. Recognition and management of acute toxicities is often the best strategy to limit more severe and potentially irreversible toxicities in this patient population. The investigation of protective agents, refinement of radiotherapy techniques, and improvement in the early recognition and treatment of esophagitis, pneumonitis, esophageal stricture, and pain have improved outcomes for patients receiving combined modality therapy for NSCLC. Managing Pain in Patients with Cancer Receiving Radiotherapy Tracy K. Gosselin, RN, MSN, AOCN: Another clinically important adverse effect of radiotherapy is pain. A survey conducted by the Radiation Medicine Department of the North Shore-Long Island Jewish Health System asked patients to rate how their pain was managed during treatment on a scale of 1 (very poor) to 5 (very good).[58] An interdisciplinary team of oncology nurses, a radiation oncologist, and a social worker assessed the scores from the questionnaires and determined that a more in-depth pain assessment was needed. Therefore, the investigators modified the satisfaction survey form to include the pain type, location, duration, cause, and desired pain level. The nursing staff found that the new assessment was easy to complete during patient visits and that its more comprehensive information led to more comprehensive interventions for pain. The investigators plan to implement personal pain diaries and develop an inpatient-specific pain survey. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Pain is universally associated with decreased quality of life and fatigue. However, it is often difficult to isolate the specific location, quality, intensity, duration, exacerbating symptoms, and alleviating symptoms and thereby create strategies to manage pain in individual patients. In addition, the subjective element of the interpretation and tolerance of pain presents a challenge to the oncology nurse. Strategies for pain management require an understanding of the underlying disease, the likelihood of pain associated with the disease itself, and the treatment of the disease, as well as consideration of the unique needs of individual patients. Continuity of care, including pain assessment, is critical to determining the characteristics of pain and the best approach to treatment for each patient. Evaluating and Treating Peripheral Neuropathy in Multiple Myeloma Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Oncology nurses play an important role in ensuring proactive management of adverse effects related to novel agents. Faiman and colleagues[59] conducted a study that assessed practice patterns of oncology nurses in the setting of myeloma. The investigators used a 23-item survey, developed with expert oncology nurse input, which was distributed to attendees of the 10th ONS Institute of Learning conference. Approximately one half of respondents were staff nurses and nurse clinicians (53%), and 82% of these had at least a bachelor’s degree. The survey focused on relevant aspects of adverse effect monitoring, oncology nursing management, and general knowledge related to myeloma and treatment with bortezomib, lenalidomide, PLD, and thalidomide. Peripheral neuropathy is a major adverse effect of many newer therapies and was the most frequently reported adverse effect of bortezomib and thalidomide in this survey. It also was noted as being the most challenging adverse effect of those drugs to manage, often with the help of anticonvulsant drugs and dose reductions. Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 14
- 15. Many practitioners (~85%) reported using gait/balance and touch/sensation to evaluate neuropathy, but far fewer (33%) reported using a standardized assessment tool for peripheral neuropathy symptoms. The data from this survey indicate that nurses need to learn more about neuropathy evaluation in myeloma and, by extension, in other indications as well. The survey authors commented that more effective nonpharmacologic prevention and treatment strategies for peripheral neuropathy are needed. Tracy K. Gosselin, RN, MSN, AOCN: Peripheral neuropathy can also affect patient safety. When patients present with numbness/tingling and/or a gait/balance issue, it is important to educate the patient and caregiver on the risk of falls and burns related to the changes in sensation. Effects on a patient’s activities of daily living also affect quality of life; therefore, early and ongoing education is important. Managing Febrile Neutropenia in Patients with Cancer Tracy K. Gosselin, RN, MSN, AOCN: Several abstracts presented at the congress were on the topic of febrile neutropenia,[60-62] which, unfortunately, continues to be a significant issue in many oncology settings despite the availability of growth factors. Although the incidence has declined, patients can decompensate very quickly when it does occur. Febrile neutropenia can delay treatment, increase the length of hospitalization, and decrease quality of life; it is a potentially fatal emergency.[60,61] Recommendations for patient education include explaining the white blood cell count and absolute neutrophil count as part of complete blood count results; blood counts should be required at each visit.[60] Patients should also be instructed to report when febrile episodes occur and what to tell emergency department staff. Nurses at the University Medical Center in Princeton, New Jersey, have developed a febrile neutropenia protocol that addresses patient assessment, treatment options with time-sensitive parameters, and patient education.[61] Using evidence-based practice, nurses at the USC Medical Center in Los Angeles developed multidisciplinary guidelines and interventions designed to help patients with risk of neutropenia avoid the need to visit the emergency room or hospitalization.[62] The chemotherapy ordering process was updated with an area for ordering growth factors, which are recommended by the NCCN for neutropenic patients.[63] The nurses included a clinical pathway that includes risk factor guidelines to identify both those at risk and when to activate the action plan. Following 2 months of staff education, it was shown that patients at risk of neutropenia were cared for better, including fewer admissions and early discharges. In addition, the recommended prophylactic use of growth factors was shown to decrease both hospital visits and neutropenia- specific admissions. A complementary abstract covered evidence-based practice at the bedside.[64] Most bedside nurses do not use an evidence-based approach, despite the availability of well-developed evidence-based practice models. Nurses from the City of Hope hospital developed an evidence- based practice model designed to address the practical needs of bedside nurses. Following 9 evidence-based practice workshops, nurses are now working on unit-based projects ranging from symptom management to nurse-to-nurse communications. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Prophylactic risk–adapted treatment strategies for patients at risk for febrile neutropenia have significantly reduced the incidence of hospitalizations for patients receiving myelosuppressive therapies. Administration of granulocyte colony–stimulating proteins based on identified risk factors including older age, bone marrow involvement, radiation to marrow-producing sites (pelvis, sternum, ribs, calvarium, femurs), splenectomy or splenic irradiation in patients with extramedullary hematopoiesis, and Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 15
- 16. chemotherapeutic regimens knownto induce myelosuppression has reduced the incidence of hospitalizations for febrile neutropenia. To be effective, however, the administration of growth factors requires patient and caregiver education regarding reportable signs and symptoms, a clear plan for discussion of laboratory values and symptoms, and implementation of a practice- specific plan for identification of patients at high risk and prevention strategies for those patients. Maintaining Adherence to Novel Oral Agents Tracy K. Gosselin, RN, MSN, AOCN: As all oncology nurses know, adherence to novel oral agents is very important to producing the best possible outcomes in cancer patients. Siehl and colleagues[65] conducted a comprehensive literature review, including results from an international survey by the Multinational Association of Supportive Care in Cancer (MASCC),[66] regarding adherence to oral therapies. Results showed that adherence rates can be as low as 20%. In my opinion, the low adherence is due in part to the specific patient population and in part to how oral agents are prescribed. The investigators’ goal was to emphasize the value of patient adherence by focusing on 3 key areas—knowledge, process, and responsibilities for healthcare providers—and to identify ways to translate those into practice and thereby enhance patient outcomes. Results showed that nurses and other healthcare professionals need to have a shared knowledge base related to information, a systematic process to employ for individual patients, and clarity and consensus regarding roles and responsibilities. In this way, the value of adherence can be recognized by both patient and provider. Although some centers successfully enable good adherence by patients to oral agents, I think many struggle with it, in relation to how well patients are doing and how effectively their symptoms are being managed. It is also important for patients to feel comfortable enough to honestly answer how adherent they are to their regimen. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Adherence is a challenge, especially with the new oral agents. As former Surgeon General C. Everett Koop noted, “Drugs don’t work in patients who don’t take them.”[67] Many patients with cancer fall outside the realm of nursing and may have infrequent contact with oncology nurses. For instance, patients who are receiving dasatinib or nilotinib for chronic myeloid leukemia come in to receive their oral medication and then may not return to see their provider for a month, during which time adherence may falter. Consistent exposure to treatment is key to bringing chronic myeloid leukemia under control. This is an example of the challenge that oncology nurses face with a population of patients who do not receive infusions and instead receive oral therapies for the treatment of their disease. There are numerous related challenges. Not knowing when a patient has prescriptions filled and when the patient starts therapy, ordering and review of laboratory tests obtained at outside facilities, and the complexity of telephone contact create potential barriers to optimal therapy. Strategies to mitigate adherence problems should be in place, such as chemotherapy education classes for patients receiving oral agents and an established plan or calendar for scheduled laboratory and clinic visits based on known risk profiles for individual treatment plans. On the flip side, another problem with not seeing patients frequently is that those who are consistently staying adherent to their regimen may not know when to stop based on adverse effects; in other words, they may continue taking their regimen when treatment should be interrupted. As providers and as nurses, it would be best in the early phase of illness to have visits scheduled at more frequent intervals to monitor adherence and tolerance, and to improve the efficacy and reduce the risk of treatment. Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 16
- 17. Tracy K. Gosselin,RN, MSN, AOCN: I agree. There are many patient factors related to their disease, drug cost, age, social support, other comorbid diseases (eg, depression, cognitive changes), and other issues that can potentially affect adherence. Seeing patients more frequently makes sense. Managing Oral Mucositis in Patients with Cancer Receiving Radiation and/or Chemotherapy Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Oral mucositis refers to inflammatory tissue damage of the oral cavity including the lips, tongue, gingiva, and the hard and soft palate. It is an especially difficult adverse effect of treatment for many patients with cancer and can cause pain, fatigue, depression, anxiety, difficulty sleeping, and changes in functional status.[68] Approximately 40% of chemotherapy patients, 75% to 100% of patients receiving high-dose chemotherapy during bone marrow transplantation, and 80% to 100% of patients receiving radiation for head and neck cancer experience oral mucositis.[69,70] Several years ago this was a hot topic in oncology, but as therapies were refined, oral mucositis became limited mainly to patients undergoing bone marrow transplantation. However, with the advent of new therapies, oral mucositis is becoming a problem again and is often underestimated in terms of pain, anxiety, difficulty sleeping, depression, and being able to eat and feel good. Much like the difficulties with neuropathy, there are several different strategies practitioners use for grading the different toxicities. These include guidelines such as the Oral Assessment Guide,[71] Oral Mucosa Rating Scale,[72] Oral Mucositis Index,[73,74] and the Oral Mucositis Assessment Scale.[69] Nurses should pay particular attention to the updated guidelines for the prevention and treatment of mucositis from the MASCC/ISOO mucositis study group.[75] However, the different guidelines are not necessarily consistent. Most mucositis treatment relies on simple processes that do not require prescription medications, including basic oral hygiene using bland oral rinses (eg, bicarbonate solution and normal saline rinses), use of a soft toothbrush, and avoidance of aggravating factors. Other options include low-level laser therapy, cryotherapy, and palifermin, which is available primarily in the bone marrow transplant setting.[76] For systemic pain management, morphine is the analgesic treatment of choice.[68] Topical anesthetics may provide temporary relief. It is important for nurses to avoid the use of sucralfate, chlorhexidine, combination mouthwashes, alcohol-containing compounds, and petroleum-based products. Tracy K. Gosselin, RN, MSN, AOCN: Screening for and assessment of oral mucositis are important for oncology nurses to understand in addition to treatment strategies. Risk factors include a history of oral cavity problems, current oral health complications, and planned cancer therapy. Summary and Conclusions Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Many of the sessions at the 2010 ONS Congress tackled the difficult concepts of personalized medicine and targeted therapies. New pathways being targeted for treatment were discussed, as were the associated unique toxicities that occur in patients who have complex disease states. The overall question is how do we, as oncology nurses, continue to play a major role in improving patient outcomes? How can nurses, including oncology nurses, new nurses, and advanced-practice nurses, make a difference every day in managing toxicities? Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 17
- 18. Nurses need tofully understand a patient’s chemotherapy regimen, understand patients as individuals, assess comorbidities, and determine how likely a patient is to respond to a given therapy for his or her tumor type. Tracy K. Gosselin, RN, MSN, AOCN: We will continue to see the evolution of treatment options, whether from a medicinal standpoint, or via surgery, radiation, or combination therapy. As nurses, we need to continue to learn how to manage evolving symptoms and understand the underlying mechanisms, because the symptoms seen 10 or 15 years ago are not the same as today. It is also important to educate patients regarding their treatment and their symptoms and advocate for their care needs. The emergence of molecular and genomic assays will continue to improve staging and may become a widespread standard of care that helps drive the use of personalized therapies. Indeed, this is another reason why more patients need to continue to enroll in clinical trials, particularly for smaller disease groups such as pancreatic, liver, and ovarian cancer for which it can be difficult to get a critical mass of patients in studies. Sandra E. Kurtin, RN, MS, AOCN, ANP-C: Ideally, symptom management strategies will be incorporated into clinical trials. Therefore, nurses need to capitalize on collaborative relationships with physician colleagues, nutrition colleagues, and others who are studying these problems. Tracy K. Gosselin, RN, MSN, AOCN: I agree. As we move forward, “team science” needs to be an integral component of the work we do along with our colleagues (eg, nurse practitioners, doctors, dietitians, social workers, counselors) as we might all approach a problem differently and study it differently. Ultimately, we share the goal of improving care and providing quality treatment and supportive care. . Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 18
- 19. To receive freeCME credit for this article, Please complete the following posttest online at: clinicaloptions.com/OncNursing2010 POSTTEST Click on the appropriate response below. 1. In the setting of colorectal cancer, what is the clinical significance of mutated KRAS? A. Significantly increased risk of neutropenia with irinotecan B. Increased risk of endometrial cancer C. Resistance to epidermal growth factor receptor inhibitors D. All of the above 2. According to a survey regarding the practice patterns of nurses with regard to immunotherapy for advanced melanoma, which of the following agents was reported as most commonly used? A. Interferon alfa-2b B. Interleukin-2 C. Ipilimumab 3. In phase II results, olaparib was shown to provide a substantial overall response rate when given at 400 mg/day in patients with advanced ovarian cancer. What type of agent is olaparib? A. Anti–vascular endothelial growth factor (VEGF) tyrosine kinase inhibitor B. CA 19-9 targeted monoclonal antibody C. Poly(ADP-ribose) polymerase (PARP) inhibitor D. Mammalian target of rapamycin (mTOR) inhibitor 4. Which of the following are important adverse effects for nurses to manage in patients with non-small-cell lung cancer receiving radiotherapy? A. Cutaneous toxicities B. Pneumonitis C. Esophagitis D. B and C are correct E. All of the above 5. All of the following EXCEPT which one are recommended supportive care for patients with oral mucositis? A. Low-level laser therapy B. Combination mouthwashes C. Cryotherapy D. Palifermin Copyright © 2010 Clinical Care Options, LLC. All rights reserved. 19
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